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< Back To Patient Safety

Patient ID Risks & the Intersection of Electronic Health Records

The AMC PSO recently convened a multidisciplinary group of stakeholders across its membership to review and discuss strategies for safer patient identification.

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For This Patient, Opioids for Pain Resulted in Suicide, Court Settlement
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO, Tom A. Augello, CRICO

The patient had a history of suicidality when her psychiatrist referred her to a sleep specialist. Three weeks after the second doctor increased her oxycodone dose to treat restless leg syndrome, the patient used the drug to kill herself.

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Being a defendant, tips from a judge, medication errors, and more
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

May 2017 Insights newsletter. See Judge Zobel’s key rules for being deposed...

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What is the “Standard of Care”?
By Jock Hoffman, CRICO, Tom Augello, CRICO

Learn how medical care is measured in legal cases.

 

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Culture Helped, Hurt in this Dosage Error
By Barbara Szeidler, RN, BS, LNC, CPHQ, CPPS, CRICO
Tom A. Augello, CRICO

In this case, an 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke. It could be said that the culture at this hospital both contributed to the error, and contributed to a good response by staff.

 

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Defendants Talk, Standard of Care, Case Studies, and more...
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

Insight February 2017:  Defendants Talk, Standard of Care, Case Studies, and more

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Let’s Be Clear About This
By Jock Hoffman, CRICO

The wrong words may be harmful.


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Opioids, Skipped Test, Wrong Dx, and more...
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

Insight January 2017:  Opioids, Skipped Test, Wrong Dx, and more.

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No Review of Test Result, and
Girl Suffers Wrong Dx for Years
By Kathy Dwyer, MSN, RN, CRICO, Terese Berry, MD, CRICO, Tom A. Augello, CRICO

An 8-year old girl was treated over three years for a condition she never had. Multiple providers missed a test result that showed she had celiac disease, so it went untreated and she suffered. The resulting lawsuit resulted in a settlement against two of her doctors. This case study not only reviews the facts, but it also features suggestions from an expert reviewer on how to prevent similar mistakes managing test results.

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Patient Safety Alerts Library

Each AMC PSO Patient Safety Alert takes an in-depth look at one or two topics such as Patient Falls and Results Management. Visit our library to see the available reports and fill out a form to receive a PDF of one or more issues. 

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21-30 of (286) items Page of 29