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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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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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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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