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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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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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Insight: Best Practices in Referral Communication
By Jennie Wright, RN, CRICO

Processes to promote ongoing communication between referring physicians and specialists are essential to providing high quality and safe patient care. To date, maintenance efforts have tended to be provider-specific rather than process based.

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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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