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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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EHR Downtime, Lost Orders, and more
By Alison Anderson, Missy Padoll, Wallinda Hutson, CRICO

Insight January 2018: EHR Downtime, Lost Orders, and more

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Poor Communication of Doctor’s Orders Leads to Preventable Death
By Missy Padoll, CRICO and Tom A. Augello, CRICO

When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.

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Harvard Primary Care Sites Collaborate on Innovations in Patient Safety, Quality
By Tom A. Augello, CRICO

For two years, The HMS Center for Primary Care partnered with CRICO, to “move the needle” in four areas of ambulatory care. A key success factor: funding so personnel from the 28 practices could meet off-site to collaborate with each other. Watch participants share how this project transformed their practices, and continues to fuel collaboration to prevent medical harm and promote care improvements.grant_icon

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Safety Culture and Risk Reliability in Health Care
By the AMC PSO

This paper explores the dynamics of safety culture and organizational resilience.

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ED Stuck on Wrong Diagnosis, Blamed the Patient?
By Tom A. Augello, CRICO, Carla Ford, MD

A 26-year-old male presented to the emergency department with burning chest pain. After two more visits within four days for the same complaint, he died at home from acute coronary thrombosis. Did the clinicians' frustration with the course of his condition lead them to blame the patient rather than reconsider their diagnosis?

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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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