Resource
is a lively program
of news, interviews,
case studies, and
legal reports
with the latest
thinking in patient
safety
and medical
liability from
experts at Harvard
and around the
world.
Resource
is produced every
other month by
CRICO/RMF in the
Harvard Medical
system,
and is provided here
through Princeton’s
partnership with
CRICO/RMF. For your
convenience, it
is available as an
MP3 download.
Instructions for
downloading MP3 and
PDF files can be
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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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