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Part I: Harvard Joins IHI to Cut Referral Mistakes Apr 16, 2018

Show notes

In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care where the doctor recommends that a patient see a specialist, but it either doesn't happen or nobody acts on the result. A new tool from The Institute for Healthcare Improvement and CRICO helps guide doctors and practices to prevent these referral errors and the harm from resulting diagnostic failures.

Poor Communication of Doctor’s Orders Leads to Preventable Death Dec 22, 2017

Show notes

When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.

ED, Stuck on Wrong Diagnosis, Blamed the Patient Nov 20, 2017

Show notes

A 26-year-old male presented to the emergency department with burning chest pain. After two more visits within four days for the same complaint, he died at home from acute coronary thrombosis. Did the clinicians’ frustration with the course of his condition lead them to blame the patient rather than reconsider their diagnosis?

NP Misses Fatal Illness on Phone with Patient’s Dad Sep 11, 2017

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A father called his son's pediatrician’s office on a winter week-end night and told the nurse practitioner that his nine-year-old had not felt well for three days. The nurse fixated on flu symptoms and told the father to push ginger ale. When the father checked on the boy 12 hours after the call, he had died from diabetic ketoacidosis and his diabetes mellitus was undiagnosed until autopsy.

For This Patient, Opioids for Pain Resulted in Suicide, Court Settlement Aug 01, 2017

Show notes

The patient had a history of suicidality when her psychiatrist referred her to a sleep specialist. Three weeks after the second doctor increased her oxycodone dose to treat restless leg syndrome, the patient used the drug to kill herself.

Culture Helped, Hurt in this Dosage Error Feb 28, 2017

Show notes

In this case, an 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke. It could be said that the culture at this hospital both contributed to the error, and contributed to a good response by staff.

No Review of Test Result, and Girl Suffers Wrong Dx for Years Dec 23, 2016

Show notes

An 8-year old girl was treated over three years for a condition she never had. Multiple providers missed a test result that showed she had celiac disease, so it went untreated and she suffered. The resulting lawsuit resulted in a settlement against two of her doctors. This case study not only reviews the facts, but it also features suggestions from an expert reviewer on how to prevent similar mistakes managing test results.

Missing an MI When Symptoms Didn’t Match Diagnosis Sep 01, 2016

Show notes

A presumptive diagnosis during an office visit kept the doctor from broadening the differential to include a much more serious condition. Commentator Carla Ford, MD says, “These are the kinds of situations that our primary care providers and urgent care providers are faced with all the time.”

Distraction, Poor Planning for OB Patient Jul 20, 2016

Show notes

Language barrier, distraction, and poor planning caused a delay in treating fetal distress. The baby was born with deficits and the settlement was >$1 million.

MedMal Huddle Looks at Communication Errors Jul 20, 2016

Show notes

Nearly 3 in 10 medical malpractice cases have identifiable problems with communication, according to a report by CRICO, the malpractice insurer for the Harvard medical institutions. Proven solutions highlighted a national gathering of patient safety leaders in Boston.

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