Resource: October 2008 
  

Patient Status Changes "Trigger" Call to MD
Strong indicators that telling nurses when to call the doctor to the bedside reduce bad outcomes.

Guest Commentators:
Michael Howell, MD, MPH
Beth Israel Deaconess Medical Center
Boston, MA

Patricia Folcarelli, RN, PhD
Beth Israel Deaconess Medical Center
Boston, MA

Closed Case Abstract:
Sleep Apnea Patient Dies After Eye Surgery
Communication and documentation flaws compromised a case that featured allegations of poor assessment and monitoring both pre-op and post-op.

Guest Commentator:
William Berry, MD, MPH
CRICO/RMF
Cambridge, MA

Legal Report:
A Physician Duty to Non-patients?
MA high court offers mixed ruling on whether a doctor is liable for patients who injure a third party after getting a prescription medication.

Guest Commentator:
Ellen Epstein Cohen, JD
Adler, Cohen, Harvey, Wakeman, Guekguezian, LLP
Boston, MA

New Ambulatory Med Safety Rules
Joint Commission pushes new standards for reconciling lists and dosage of medications as patients change settings.

Guest Commentator:
Peter Angood, MD
Joint Commission on the Accreditation of Healthcare Organizations
Oak Brook Terrace, IL

Nancy Manchester
Atrius Health
Newton, MA 

Jeffrey Schnipper, MD, MPH
Brigham and Women's Hospital
Boston, MA

Resource: August 2008 
  

Special Report:
Health IT Brings Solutions, New Problems  

Hundreds of caregivers and health IT experts gather in Boston to consider the bad and the good of using information technology for patient safety.

Part I:
Tech Aids for Decision Making (10:04)

Seeking the benefits for better prescribing, diagnoses, and treatment decisions, while avoiding risks of work-arounds and bad implementation. 

Guest Commentators:
David Bates, MD, MSc
Brigham and Women’s Hospital
Boston, MA

John Glaser, PhD
Partners HealthCare System
Boston, MA

Judy Murphy, RN
Aurora Healthcare
Milwaukee, WI

Part II:
Electronic Help for Follow Through (7:00)

Reliability for test result and referral management can be accompanied by confusion and conflicting electronics.

Guest Commentators:
John Halamka, MD, MS
CareGroup Health System
Boston, MA

Dan Rosenthal, MD
Massachusetts General Hospital
Boston, MA

Eric Poon, MD, MPH
Brigham and Women’s Hospital
Boston, MA

Closed Case Abstract:
Deaths Preventable with Computers (6:45)

Systems could have helped one doctor to consider colon cancer screening, and another doctor to follow up on a referral.

Guest Commentator:
Luke Sato, MD
CRICO/RMF
Cambridge, MA

Legal Report:
Three Risks to Avoid in Health IT (3:32)

Be on the lookout for inaccurate templates, inconsistent records across formats, and missing information from print-outs.

Guest Commentator:
Ellen Epstein Cohen, JD
Adler, Cohen, Harvey, Wakeman, Guekguezian
Boston, MA

Resource: March 2008 
  

Program Summary:
MD Empathy: The Patient Perspective (10:22)

Physicians who express empathy get higher ratings by their patients on other care issues.

Guest Commentators:
Ronald Epstein, MD
University of Rochester Medical Center 
Rochester, NY

Wendy Levinson, MD
University of Toronto Department of Medicine
Toronto, Ontario

Debra Roter, DrPH
Johns Hopkins School of Medicine and School of Nursing
Baltimore, MD

Case Abstract:
Delayed Diagnosis of Post-op Infection (9:34)

Care required better resident supervision, closer follow-up on ordered test.

Guest Commentator:

William Berry, MD, MPH
CRICO/RMF
Cambridge, MA

The Nature of Resident Errors (9:34)

Research points to flawed hand-offs, judgment, and supervision.

Guest Commentators:
Sheila R. Barnett, MD
Beth Israel Deaconess Medical Center
Boston, MA

Aaron S. Kesselheim, MD, JD
Brigham and Women’s Hospital Boston, MA

Hardeep Singh, MD, MPH.
Baylor College of Medicine
Houston, TX

Legal Report:
Lost Evidence Loses Cases (6:15)

Fetal monitor strips, family history forms, and other non-medical record documents need to be preserved.

Guest Commentator:
Ellen Epstein Cohen, JD
Adler, Cohen, Harvey, Wakeman, Guekguezian, LLP
Boston, MA

Resource: January 2008 
  

Program Summary:
Are Intact Surgical Teams Possible
for Safety? (10:47)

A gathering of surgeons
confronts rotating personnel in
operating rooms as a barrier to
using team methods for
patient safety.

Legal Report: Openness and Caution
in Disclosing Adverse Events (7:48)

A defense attorney’s
perspective on telling patients
what is known after an
unexpected adverse event.

Some Real World Solutions for Rising
Diagnosis Problems (7:00)

Tracking test results in
ambulatory care and
responding rapidly to in-patient
crises are among the sharings
from two health systems.

Closed Case Abstract: Decreased
Fetal Movement In Diagnosis (5:39)

Researcher explores new
opportunities to use reduced
movement in diagnosing and
possibly preventing fetal
demise.

News Briefs (1:35) 

Resource is produced by CRICO/RMF, the patient safety and medical malpractice company owned by and serving the Harvard medical community since 1976.

RMF Strategies, a division of CRICO/RMF, provides evidence-based risk management services and software solutions to healthcare systems and medical malpractice insurers.

© 2008 CRICO/RMF. All rights reserved. 

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