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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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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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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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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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Could this Happen in Our Practice?
By Jock Hoffman, CRICO

Learning from the past to improve patient safety.

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Patient Voice: Beth Felt a Lump but the Nurse Didn’t. How a Patient and her Providers Turned it Around
By Tom A. Augello, CRICO

Patient Voice: Beth felt a lump in her breast but the NP covering for her regular primary care doctor told her there wasn't a need for testing because she didn't feel it. An insistent patient, a concerned doctor, an apology, stellar coordination with specialists, and remission complete the story. Now, this patient praises her health care providers and the institutions they work in.

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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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CRICO’s Are You Safe? Case Studies

These case studies are designed to help all members of a multidisciplinary team reduce the risk of patient harm in the course and diagnosis and treatment. Office-based events that trigger malpractice cases present valuable opportunities to identify vulnerabilities in communication, clinical judgment, and patient care systems.

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Are You Safe? Overview

CRICO works closely with your organization’s Patient Safety and Risk Management staff to build expert resources for individual and team-based education and training.

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Are You Safe? Library

Are You Safe? cases are available as double-sided single sheets or slideshows that you can use to discuss improving patient safety in the office setting. This page lists all items by topic. Click through to see how you can earn category 2 Risk Management credits.

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