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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
found
at the bottom of
this page Click here
Resource: April 2009
New Decision Tool
for Prostate Cancer
Testing
[8:40]
A consent discussion
with patients leads
the PSA testing
advice in a
Harvard-generated
document to help
primary care MDs
manage prostate
care.
Guest Commentators:
Marc Garnick, MD
Beth Israel
Deaconess Medical
Center
Boston, MA
Richard Parker, MD
Beth Israel
Deaconess Medical
Center
Boston, MA
Closed Case Abstract
Drug Error Reviewed
by Non-Healthcare
Methods
[10:19]
A patient safety
audience hears about
how outside industry
might fix a process
breakdown before or
after a wrong drug
error.
Guest Commentators:
Steven Spear, DBA,
MS, MS
MIT
Cambridge, MA
Legal Report
Court Defines a New
Harm for Losing a
Chance at Survival
in Massachusetts
[6:21]
Even if negligence
didn’t cause a
patient’s death, it
may be compensable
if it lessened the
chance of survival.
Philip Murray, Jr.,
JD
Murray, Kelly &
Bertrand, PC
Woburn, MA
Patient Safety Data
Driving Change: A
Model Methodology
[8:09]
Checklists,
automation,
simulation, drug
abbreviations, or
marking the surgical
site—it all starts
with error data and
re-starts with
outcome measures.
Guest Commentators:
Robert Hanscom, JD
CRICO/RMF
Cambridge, MA
James Pichert, PhD
Vanderbilt
University
Nashville, TN
Luke Sato, MD
CRICO/RMF
Cambridge, MA
Tom Snyder
Princeton
Insurance
Princeton, NJ
Resource: December
2008
Special Report:
A Patient Safety
Intersection:
Simulation and Team
Training
Harvard Symposium 2008
Part I:
Momentum for
Scenarios to Cut
Medical Error [9:40]
In the arsenal of
weapons against
medical error,
health care
institutions are now
reaching for two at
the same time:
simulation and team
training.
Guest
Commentators:
William Dunn, MD
President
Society for
Simulation in
Healthcare
Mayo Clinic,
Minneapolis
James Gordon, MD,
MPA
Director
Gilbert Program in
Medical Simulation
Harvard
Medical
School,
Boston
Luke Sato, MD
Chief Medical
Officer
CRICO/RMF,
Cambridge
Susan Mann, MD
Director
Quality Improvement
for OB/GYN
Beth
Israel
Deaconess
Medical
Center,
Boston
Jeffery Cooper, PhD
Executive Director
Center for Medical
Simulation,
Cambridge
Charles Pozner,
MD
Medical Director
STRATUS
Center
for Medical
Simulation
Brigham and Women’s
Hospital,
Boston
Peter Weinstock, MD,
PhD
Technical Director
Simulator Program
Children’s Hospital,
Boston
Case Study: [8:26]
Pedi Hands-off Simulated in ED
In situ simulation
demonstrates how
debriefing surfaces
system and
communication
problems in
hand-offs, managing
emergent resources.
Guest Commentator:
William Hamman, MD
Professor and Co-Director,
College
of
Aviation
Center
of
Excellence
for Simulation and
Research
Western
Michigan
University,
Kalamazoo
Part II: [8:36]
Are You Ready for
Simulation and Team
Training?
Medical leaders
envision a future
where physicians and
nurses routinely
step into simulation
labs to hone
clinical skills and
team techniques and
what it takes for an
individual
institution to get
there.
Guest Commentator:
J. Bryan Sexton, PhD
Anesthesia/Critical Care Medicine
John
Hopkins
University,
Baltimore
Britain
Nicholson,
MD
Chief Medical Officer
Massachusetts
General
Hospital,
Boston
John L. McCarthy
President
CRICO/RMF,
Cambridge
Arvind Agnihotri,
MD
Cardiac Surgery
Massachusetts
General
Hospital,
Boston
Carol Luppi, RN
Nurse Educator for Technologyl
Brigham and Women's
Hospital,
Boston
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.
© 2009 CRICO/RMF.
All rights reserved.
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