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Part III: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

According to estimates, as many as half of medical specialty referrals are not fully completed. In a study of medical malpractice cases asserted in the Harvard system between 2006 and 2015, 46 cases involved referral breakdowns, with an incurred cost of $11 million. The vast majority involved severe harm to the patient. Closing the Loop... is a guide to prevent this from continuing.

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Part II: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

Mishandled specialty referrals in ambulatory care can harm patients and lead to litigation if a diagnosis is delayed or missed. Two leading groups hope individual practices and institutions will use the Guide to make their referrals more reliable and reduce mistakes.

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Part I: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care where the doctor recommends that a patient see a specialist, but it either doesn’t happen or nobody acts on the result. A new tool from The Institute for Healthcare Improvement and CRICO helps guide doctors and practices to prevent these referral errors and the harm from resulting diagnostic failures.

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EHR Downtime, Lost Orders, and more
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

Insight January 2018: EHR Downtime, Lost Orders, and more

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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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Malpractice Risks Associated with Electronic Health Records
By Penny Greenberg, MS, RN, CPPS, CRICO and Gretchen Ruoff, MPH, CPHRM, CRICO

Read this study about whether or not EHR use has unintended consequences that detract from the safety of health care.

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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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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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Electronic Health Record Risks in the Emergency Department

The AMC PSO convened a panel of Emergency Medicine thought leaders to identify significant areas of concern and to explore potential mitigation strategies for use of electronic health record risks in the Emergency Department

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Starting Points for Patient Safety
By Jock Hoffman, CRICO

Patient Safety: Benchmark before improving. Learn how.

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