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Strategies for Patient Safety (SPS) Library

Related to: Publications

Each month, Strategies for Patient Safety explores the myriad ways 30-plus years of analyzing medical malpractice data can guide physicians and nurses practicing amidst today’s patient safety risks. We view SPS as an opening to deeper exploration of issues that impact your patients, your practice, and your professional well-being.


July 2021–Residents and Fellows and Malpractice
Supervising attendings and other team members should lead trainees from any missteps toward learning opportunities.

June 2021–MPL Case Management Expenses 
Even without a payment, cases still incur defense costs

May 2021–In the Name of Respect
Good rapport begins with first impressions.

April 2021–Opening the Door to Safe Virtual Visits
When one door closes, another one opens. —Alexander Graham Bell

March 2021–At the End of Information Blocking, an Opening for Patient Safety 
The Cures Act unblocks access to all health care notes.

February 2021–More Recently Asked Questions 
Queries about malpractice and patient safety.

January 2021–Recently Asked Questions
Clinicians express concerns about malpractice and patient safety.



Diagnosing the Malpractice Risks for Radiologists 
62% of cases naming radiologists allege a diagnostic error.

November 2020–Risks Associated With the Most Common “Procedure” Clinicians Employ
Heed unsatisfactory conversations.

October 2020–Too Good to Be Untrue
Medmal data is a credible source for patient safety.

September 2020 - Documentation Gaps Increase the Risk of a Malpractice Defendant Being Held Responsible
Inadequate or missing information increases the likelihood of payment 76%

August 2020–An Inadequate Patient Assessment Increases the Risk of a Malpractice Defendant Being Held Responsible
Presence of this factors increases likelihood of payment 85%.

July 2020–Policy Protocol Missteps More Likely to Result in Paid Claims
Presence of this factors increases likelihood of payment 145%.

June 2020–Who’s Seeing Your Patients? 
Signs and symptoms of illness may go undetected

May 2020–It Won’t Be Easy
Some patients will find post-quarantine care especially difficult.

April 2020–Going Beyond in the Time of COVID-19
There’s a lot to learn in a hurry.

March 2020–Managing Non-coronavirus Patients’ Expectations Amid the Pandemic 
Managing non-COVID-19 patients in overtaxed health care environment.

February 2020–Asking the Right Questions About Risk 
Better questions lead to better answers.

January 2020–MPL Risks Associated with PAs 
PA patient safety risks mirror MDs.



December 2019–MPL Risks Associated with NPs
Fewer than one percent of MPL cases name an NP.

November 2019–Doorknob Syndrome and Patient Safety
Patients don’t always start at the top of their problem list.

October 2019–Medical Malpractice Jury Verdicts are Rare
No day in court.

September 2019–Good News is No News 
Patient safety is improving…despite the headlines.

August SPS August 2019–Are Best Practices (Still) a Good Idea?
SIf you need a best practice, where do you look?

July 2019–MPL Case Studies Aligned with Top Diagnostic Risks
What often gets missed.

June SPSJune 2019–Why Went Wrong 
From errors to opportunity

May 2019–A Difficult Time for Patient Safety
Beware the end of day challenges.

April 2019–Taking a Second Look at Nursing Malpractice Cases
Nursing’s less obvious involvement in medmal cases.

March 2019 –What Should You Worry About? 
Pick your patient safety battles.

February 2019–Some Good News about Medical Malpractice in America 
27% drop in medmal cases

January 2019–Fixing Broken Guitars 
Disrespect impacts malpractice claims.



December 2018–It’s Time to Have a Meaningful Conversation about Medical Errors
Get data and get case examples.

November 2018–In Case You Were Wondering About Malpractice Data
Quelling doubts about MPL data.

October 2018–How Patients Filter Clinician Communication
Health care comprehension varies by patient

spsSeptember 2018–Beyond the Headlines for Large Malpractice Awards 
Large awards are rare and not always instructive for patient safety.

August 2018–The Impact of Disruptive Behavior in the OR
Savvy leaders are making the connection between communication failures as a root cause of adverse events and malpractice suits in their hospitals.

July 2018–Malpractice Risks at the Front Line of Cancer Detection
Most cases involve the most common cancers.

June SPSJune 2018–How Residents Learn from their Mistakes 
Clinical judgment comes with experience

May SPSMay 2018–Exploring the “Allegation” of Medical Malpractice
Diving into specifics helps guide remediation

April 2018–The Risk of an Incomplete Patient Assessment
A pathway to missed diagnoses and substandard care.

March 2018 –Malpractice Cases Involving Non-Adherent Patients 
Bad decisions are not always dead ends

February 2018–Emerging Risks in Interventional Radiology 
IRs are the new ORs

January 2018–Habit Forming 
Forming habits is a challenge.



December 2017–Old is the New Middle Age
Don’t judge by date of birth.

November SPSNovember 2017–Toward an Ideal Referral Process
Fixing gaps in outpatient referrals.

October SPSOctober 2017–Where Things Go Wrong
Patient injury can happen anywhere

September SPSSeptember 2017– According to Multiple Sources 
Triangulation of patient safety risk

August SPSAugust 2017–10,000 Medical Apps & Counting
There’s a lot of apps for that.

July SPSJuly 2017–When Things Go Wrong for Residents 
Learning from mistakes is more challenging for residents.

June SPSJune 2017–The Dutch Reach Challenge 
Capitalizing on near misses

May SPSMay 2017–An In-depth Analysis of Medication-related Malpractice Cases
One of nine medmal cases involves medication errors

April 2017–A Handful of Opportunities to Reduce the Risk of Being Sued 
The 80-20 rule applies to patient safety.

March 2017–What’s the “Standard of Care”? 
What’s expected of doctors and nurses?

February 2017–What is this Case About? 
A narrower focus has broader impact

January 2017–Let's Be Clear About This 
Clearly, words matter



December 2016–Could this Happen in Our Practice? 
Are you safe? Find out.

November SPSNovember 2016–Please Pass the Family History 
Ace the family history test.

October SPSOctober 2016Narrowing the Focus on Diagnostic Errors
Signals for action.

August SPSSeptember 2016– Starting Points for Patient Safety 
Benchmark before improving.

August SPSAugust 2016– A Patient Safety Survey Course 
Refresh your patient safety knowledge.

July SPSJuly 2016–Who’s Who in Patient Safety 
We all provide safety.

June SPSJune 2016– Rosie’s Story 
Numbers need a narrative

May SPSMay 2016–A First Place Mindset About Medical Error 
Doing “something” deliberately

April SPSApril 2016–Milepost 40 
Celebrating 40 years of patient safety innovation

March SPSMarch 2016–Forgetting to Remember 
Is your fallible memory interrupting your sleep?

February SPSFebruary 2016–Are You on Solid Footing for Patient Safety? 
Patient safety self-assessment

January SPSJanuary 2016–The Malpractice Risks of Health Care Communication Failures 
Unreliable communication exposes patients to harm



December 2015–A Year’s Worth of Patient Safety 
12 ways to improve patient safety

November SPSNovember 2015–An Interest in What Went Wrong? 
Why do the mistakes that enable patient injuries reoccur?

October SPSOctober 2015–Is a White Coat a Scary Halloween Costume? 
Not everyone is disgruntled.

September SPSSeptember 2015– Figuring Out Diagnostic Errors 
Malpractice claims are a valuable resource. 

August SPSAugust 2015– Distribution of Injury Severity in MedMal Cases 
Not all injuries are severe or permanent. 

July SPSJuly 2015– Patient Safety Playlist 
Songs that may serve to remind and inspire you to keeping doing this important work.

June 2015– Understanding Dropped, Denied, & Dismissed Malpractice Cases 
Key factors that can drive the initiation of a weak malpractice allegation

May SPSMay 2015– Dropped, Denied, & Dismissed Malpractice Cases 
What happens to most malpractice claims?

April SPSApril 2015– “Doc Fix” Bill Might Improve Patient Safety, Too 
New federal law promotes patient safety.

March SPSMarch 2015– Miscommunication: Who, What, Where, When, How, and Why? 
Communication breakdowns need your undivided attention.

February SPSFebruary 2015–Real Events, Real Opportunities for Improvement 
A new tool for improving patient safety.

January SPSJanuary 2015–What Keeps My Doctor Up at Night 
A focal point for patient safety improvement is essential.




December 2014–Malpractice Risks in the Diagnostic ProcessDecember SPS
Study some of the problems that can impede a prompt and accurate diagnosis.

November 2014–The ABCs of Patient SafetyNovember SPS
Every acronym is an opportunity.

October SPSOctober 2014–Patient Safety and Your New Job
Learning your new job’s patient safety culture is an on-boarding task.

September SPSSeptember 2014–Tackling Trouble
The NFL can learn from patient safety.

August SPSAugust 2014–Big (malpractice) Data
Access a treasure trove of malpractice data.

July SPSJuly 2014–Can You Believe It?
CRICO attendees are envisioning a safer health care environment.

June SPSJune 2014–When a Patient Hits Record
Unauthorized recording by patients is a growing concern.

May SPSMay 2014–Practicing Anti-Social Medicine
Unauthorized release of patient images, conversations, or identifiable health care encounters are potential grounds for litigation.

April SPSApril 2014–Clinical Judgment Call
Allegations of a missed diagnosis impugn clinical judgment at many steps along the diagnostic path.

March SPSMarch 2014–Beer, Beards, and Patient Safety
The World Champion Red Sox offer a unique lesson on the impact of culture change.

February SPSFebruary 2014–When Your Patient Can’t Read Along
Outcomes linked to the patient’s reading or math ability can mean trouble for caregivers.

January SPSJanuary 2014–Obamacare and Malpractice
Speculation abounds on how the anticipated increase in patient encounters will impact patient safety.




SPS December 2013December 2013 – When a Procedure is Anything but Routine 
More than half (56 percent) of the procedure-related cases in the Comparative Benchmarking System (CBS) studied, named a physician.

SPS November 2013November 2013 – Please Pass the Family History
A good opportunity to capture information that may be vital to your patients’ long term health.
SPS October 2013October 2013 – Aha
The organizations you work for or with share your obligation to turn an aha moment into a change for the better.

SPS September 2013September 2013 – Rest Insured 
A good malpractice insurance program can also provide peace of mind.

August SPSAugust 2013 – An RCA to Remember
Looking beyond the obvious cause of an adverse event reveals hidden risks.
July 2013 SPS July 2013 – Is “My Bad” Ever a Good Idea?
Patients remember what you said, or didn’t say, to them.




June 2013 – What’s My Risk of Being Sued (I’m a Radiologist)?
Failure to diagnose breast cancer is the most common allegation.


May 2013 – Star Power
Proper management of genetic testing begins with aligning expectations.


April 2013 – Mr. Rogers Would Have Been Proud
Allegations of a missed diagnosis impugn clinical judgment at many steps along the diagnostic path.  

March SPS 2013March 2013 – A Bad Err Day
Knowing what throws you off your game enables you to add an extra ounce of vigilance to prevent patient harm and, perhaps, an allegation of malpractice.

SPS February 2013February 2013 – Build a Better EMR
Patient safety experts see enormous potential in both the point-of-care opportunities for avoiding errors and the broader value of data aggregated from appropriately designed systems.


January 2013 – Breast Density and Patient Safety
Providers have to convey to patients with dense breasts, both sides of the potential consequences of additional screening without increasing their own risk of being deemed liable for a missed or delayed breast cancer diagnosis.

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