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< Back To Patient Safety

Catching Transitioning Patients Before They Fall (through the cracks)
By Tom A. Augello, CRICO

Better clinical outcomes, lower cost: we’re talking about care transitions and a recently completed research project at Cambridge Health Alliance that identified a patient population that needs specialized help after a hospitalization. Our interview is with Dr. Richard Balaban, who led the care transition project, funded through a grant from CRICO.

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Getting Boards on Board with Patient Safety
By Tom A. Augello, CRICO

On this episode we are at the IHI/NPSF Lucian Leape Institute’s 10th Annual Forum. Patient safety luminaries from around the world gathered near Boston to review a new study on public perceptions of medical error, to discuss new trends, and to generate ideas on a singular focus: how to more fully engage a healthcare organization’s governing board to make care better and safer.

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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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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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CRICO Podcasts Home

Case studies and interviews are aligned with clinical specialties and high risk areas identified in the Harvard system.

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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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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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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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Medication Administration in the Ambulatory Setting

The AMC PSO convened a panel of nursing leaders to review risks in the medication delivery processes in the ambulatory setting and discuss potential interventions aimed at mitigating the risks associated with medication administration.

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