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NP Misses Fatal Illness on Phone with Patient’s Dad
By Kathy Dwyer, MSN, RN, CRICO, Tom Augello, CRICO

A father called his son’s pediatrician’s office on a winter week-end night and told the nurse practitioner that his nine-year-old had not felt well for three days. The nurse fixated on flu symptoms and told the father to push ginger ale. When the father checked on the boy 12 hours after the call, he had died from diabetic ketoacidosis and his diabetes mellitus was undiagnosed until autopsy.

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Cancer Diagnosis, Doctors in the Courtroom, and more…
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

Insight March 2017:  Cancer Diagnosis, Doctors in the Courtroom, and more

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

The wrong words may be harmful.


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Understanding “Standard of Care” A Doctor and a Lawyer Share from the Medmal Front Lines
By Carla Ford, MD, John Reardon, JD, Tom Augello, CRICO

For many in the medical profession, some of the basics of law and malpractice claims are a little mysterious. The key question about negligence is whether or not the provider failed to meet the “standard of care.” But how do we know what the standard of care is? We hear from a lawyer and and a doctor about what they’ve learned working in the world of medical errors and malpractice law.

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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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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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Resources for Presenters

The CRICO Are You Safe? case studies contain information that you can access in different formats: web pages, one page handouts, and a slideshow version with additional data included.

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Uncle Sam, Please Pass the Family History
By Jock Hoffman, CRICO

An assessment without family history is an incomplete assessment.

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Who’s Who in Health Care?
By Jock Hoffman, CRICO

It’s not always clear who does what.

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