Communication Failures Report
Malpractice Risks in Communication Failures
This Candello Report looks at 7,149 cases in which facts, figures, or findings got lost between the individuals who had that information and those who needed it—across the spectrum of health care services and settings.
Our Case Studies
CRICO's case studies educate you on what can go wrong in clinical settings and how you can prevent similar issues.
Communication Issue Leads to Retained Foreign Body
Following successful cranial surgery, a 54-year-old man experienced back and lower extremity pain which was ultimately diagnosed as being related to an intrathecal lumbar catheter left behind at the time of surgery eight months earlier.
Improper Management and Lack of Communication Causes Significant Post-Surgery Complications
Failure to Diagnose Myocordial Infarction
A 77-year-old with a pre-op history of abnormal EKGs died in the PACU following a cholecystectomy
Test Result Snafu Delays Cervical Cancer Diagnosis
A patient never received her abnormal test results or her associated need for follow up, leading to a delayed cervical cancer diagnosis.
CRICO Grant Spotlight: A Verbal Electronic Surgical Safety Checklist for the Intensive Care Unit
This CRICO grant-funded project showed that an electronic checklist could accurately verbalize information needed for a SICU time-out and could deliver objective information from the EHR at the point of care.
CRICO Grant Spotlight: Breast Cancer Risk Assessment Among Women 40–49 in Primary Care
Through a CRICO grant-funded project, Mara Schonberg, MD, MPH, sought to learn if providing women age 40-49 with information about their risk of breast cancer is useful to them when deciding on breast cancer screening and prevention interventions. Participants completed a pre-test, received their personalized breast cancer risk report, saw their primary care clinician, and completed a post-test.
Advisory: Detecting and Reporting Patient Safety Risks in Virtual Care Delivery
On September 23, 2021, the Academic Medical Center Patient Safety Organization (AMC PSO), in association with the Alliance for Quality Improvement and Patient Safety (AQIPS), hosted the first National Safe Table for PSOs on the topic of detecting and reporting patient safety risks associated with virtual care delivery.