Safety Net

Some top-line conclusions are that outpatient harm was relatively common and often serious, with a call to action for intervention in outpatient errors. Drs. David Levine and David Bates of Brigham and Women’s Hospital and Harvard Medical School are joined by their co-author and CRICO Chief Medical Officer, Dr. Luke Sato, who leads our discussion.

Several Harvard-affiliated medical institutions are piloting a program to provide personalized feedback to physicians about the effect of their behavior and interactions on others. More than 675 individuals have gone through the Rapid Pulse 360 evaluations as of Spring 2024. Can it have an impact on employment practices claims or provider-to-provider communication factors? And can follow-up one-to-one coaching help?

As artificial intelligence, or AI, takes off in the public sphere, what about medicine? The health care industry has been using some form of AI for decades, yet very recent advancements are upping the ante. This episode of Safety Net presents excerpts from a recent talk to malpractice attorneys by health care AI expert, Dr. Steven Horng, MD, MMSC, of Beth Israel Deaconess Medical Center and Harvard Medical School.

The Harvard teaching hospitals and their affiliated institutions have banded together to tackle one of the most difficult and deadly challenges that face all health care providers: clinical tests and specialty referrals that are lost to follow-up. Anecdotal evidence already shows patients who were rescued by the Ambulatory Safety Net project. Navigators are convincing patients to follow through, and results are being flagged.

In late 2023, the Academic Medical Center Patient Safety Organization issued an advisory noting a spike in reports of retained surgical items. A retained surgical item is patient safety lingo for when the surgical team leaves something like a sponge or a tool inside the patient after surgery. These events may lead to serious harm, such as sepsis, prolonged hospitalization, the need for subsequent surgery, or death.

The topline data from Candello claims analysis do not show an increase in malpractice corresponding to the increased use of APPs. In fact, the claims rate may be declining, adjusting for practice population increases.

A former doctor defendant found meaning after the ordeal despite her lack of preparation or role models. Dr. Gita Pensa, an emergency medicine physician, made it her professional focus to help other physicians through to the other side of the litigation journey.

The boarding of critical care patients in the emergency department is an increasing concern because ICUs are often also too full to take them.

Healthcare providers are facing new threats from online attacks that require new strategies to limit liability, harm to patients, and revenue loss. In spring of 2023, the Academic Medical Center Patient Safety Organization (AMC PSO), issued an updated Patient Safety Alert: Cyber Security and Recovery, available on the CRICO web site.

A new study that looks at when, where, and how medical errors occur in the in-patient setting is shining a bright light on threats to patient safety and quality in health care. A topline result of a 25 percent error rate for hospital admissions is getting a lot of attention. Lead author David Bates and others explain the implications for everyone in health care from the board room to the bedside.