CRICO Insights: February 2020

CRICO’s Academic Medical Center Patient Safety Organization (AMC PSO) identified “Just Culture” actions that are important factors of a health care safety culture.

Five “Just” Ways to Foster a Collaborative Safety Culture

1.

Make a personal commitment to making care safer

2.

Foster a blame-free environment across ranks and disciplines that welcomes curiosity about why errors occur

3.

Encourage a risk-learning culture by reporting system vulnerabilities, as well as sharing your own near misses and errors

4.

Support organizational efforts that make you feel comfortable speaking up, without fear of punishment

5.

Examine the relevance of your practice’s current operational and safety practices and policies—advocate for any needed adjustments

Understanding where risk exists and responding fairly helps create psychologically safe environments supportive of error reporting. Read more...


podcastPODCAST + CASE STUDY

Radiology Didn’t Know Risk Status Before Patient Fall, Head Injury

In the time the radiology technologist stepped away to take the image, the patient became unstable and fell, sustaining face and head injuries. How did this happen?

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Physicians Needed for Malpractice
Tribunal Service

To proceed to trial, Massachusetts medical malpractice lawsuits must undergo review by a tribunal. CRICO encourages you to participate in this important part of the legal process. The courts need your help...

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The Power of the Picture

Innovations in patient safety do not have to be complicated. Brigham & Women’s Hospital tested a simple intervention to reduce medication errors: patient photos in the EHR. How well did it work?

studyCASE STUDY

Mistaken Assumptions After
Surgical Complication

A 60-year-old male with diabetes and prostate cancer lost vision in his right eye after extensive bleeding during surgery to remove his left kidney and adrenal gland. What went wrong?

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Chronology of a Malpractice Case

Dr. Claire Cronin explains the real process of a medmal case, and how CRICO gets it wrong. It starts with denial...

Latest News from CRICO

Get all your medmal and patient safety news here.

    Utilization of Electronic Health Record Sex and Gender Demographic Fields: A Metadata and Mixed Methods Analysis

    News
    CRICO Grants
    This CRICO co-funded retroactive study published in the Journal of the American Medical Informatics Association analyzed the records of patients 18 years of age or older in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between 2018 and 2022. The study was important because "Sex and gender demographic data are widely viewed as essential to providing culturally responsive gender affirming care and facilitating research and public health interventions."

    The Safety of Outpatient Health Care

    News
    Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. This study looks at adverse events in outpatient settings.

    The Patient Safety Adoption Framework: A Practical Framework to Bridge the Know-Do Gap

    News
    CRICO Grants
    Many patient safety initiatives fail to be adopted and implemented, even when proven effective. This creates the well-recognized know-do gap—which occurs when health care workers know what should be done based on evidence vs. what takes place in practice. To address this issue, CRICO funded the development of a patient safety adoption framework and had it evaluated by leaders in quality and safety. The framework and its findings were published online in the Journal of Patient Safety in April 2023.
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