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Part I: Harvard Joins IHI to Cut Referral Mistakes
By Tom A. Augello, CRICO

In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care where the doctor recommends that a patient see a specialist, but it either doesn’t happen or nobody acts on the result. A new tool from The Institute for Healthcare Improvement and CRICO helps guide doctors and practices to prevent these referral errors and the harm from resulting diagnostic failures.


Patient Safety Discussion Toolkit for System Expansion
By Ariadne Labs in partnership with CRICO/Risk Management Foundation of the Harvard Medical Institutions

The Patient Safety Discussion Toolkit for System Expansion has been developed by Ariadne Labs in partnership with CRICO, for use by physicians during the pre-affiliation phase of a merger, acquisition, or affiliation of two organizations that provide clinical care. This discussion toolkit can help clinical leaders identify differences in clinical practice, resources, and culture that are most likely to affect patient safety. grant_icon


Malpractice Cases Involving Non-Adherent Patients
By Jock Hoffman, CRICO

Make an effort to find out why your patient ignores your advice.


Insight: Best Practices in Referral Communication
By Jennie Wright, RN, CRICO

Processes to promote ongoing communication between referring physicians and specialists are essential to providing high quality and safe patient care. To date, maintenance efforts have tended to be provider-specific rather than process based.


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

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


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.


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


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

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


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?


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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