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< Back To Patient Safety

Lack of Preparation, Safety Culture, Contributed to Loss of Baby
By Tom A. Augello, CRICO Jennifer Vuu Sanchez, CRICO

This OB patient’s risk factors were not adequately considered, and the team’s failure to follow protocols and secure back-up contributed to a lawsuit and a settlement of over $1 million.

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At the End of Information Blocking, an Opening for Patient Safety
By Jock Hoffman, CRICO

Opening your notes offers the potential to enhance patient safety by linking clinicians and patients between visits–times when ambulatory vulnerabilities often compound.

 

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More Recently Asked Questions
By Jock Hoffman, CRICO

Queries about malpractice and patient safety.

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Recently Asked Questions
By Jock Hoffman, CRICO

Clinicians express concerns about malpractice and patient safety.

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Word to the Wise: Misuse of Language in Clinical Communication Causes Harm
By Tom A. Augello, CRICO

Misuse of language can have serious clinical consequences. It can also leave patients and families with a bad impression or misunderstandings. We invited two physicians who authored a JAMA Perspective on the topic to explain what worries them and what doesn’t, when it comes to the misuse of words in medicine.

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“What Else Might This Be?” Might Have Saved PE Patient
By Melissa DeMayo, CRICO, Tom A. Augello, CRICO

A fatal PE misdiagnosis may have gone wrong from the very beginning. With analysis based on closed claims in the Harvard medical system, urgent care specialist Jonathan Einbinder explores ways an ordinary case with a tragic outcome might be prevented in the future.

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Reducing the Occurrence of Malpractice Cases Involving Policy or Protocol-related Breakdowns
By Jock Hoffman, CRICO

Organizations need to work within a just culture framework that looks beyond the individuals to fully understand why certain policies are sidestepped.

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Reducing the Occurrence of Malpractice Cases Involving Inadequate Patient Assessment
By Jock Hoffman, CRICO

While standardization—even automation—may be attractive, interventions to reduce errors during these critical initial stages of diagnostic assessment need to support the heuristics and mental shortcuts clinicians rely on to be effective and efficient.

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Status Change Missed, Consultation Flawed, and the Patient Loses Baby
By CRICO Staff

In this case, communication between the primary provider and a phone consultant needed more clarity. And changes in the patient’s status needed a stronger response, if a tragic outcome had any chance of being averted.

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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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