Crico Patient Safety Updates: Medical And Legal Perspectives

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.

Admitting patients to their own homes for hospital care: many factors are coming together to make the “Home Hospital” a hot topic in health care delivery. A roomful of defense attorneys in Boston recently heard about the risks and benefits from the MGB leader in charge of the largest such program in the country.

When it comes to medical notes in patient charts, copying and pasting carries risks of confusion, patient harm, and liability for providers.

Recent data from the National Academies of Science, Engineering, and Medicine show that sexual harassment and gender discrimination affect up to 50 percent of women medical students and more than 50 percent of women faculty in medicine. It affects men too.

It is estimated that thousands of medical specimens are lost each month. The impact on the diagnostic process when a specimen is lost is of particular concern. In early 2022, a patient safety document was published by the Academic Medical Center Patient Safety Organization, or AMC PSO, to describe ways to prevent harm to patients when specimens are lost. Safety Net interviews two participants with some advice for QI.

Hundreds of patients are harmed in OR fires every year. Experts in patient safety want hospitals and providers to focus more on lowering the potential for fire during surgery.

The use of simulation in health care has grown worldwide. This year and through 2028, industry business analysts expect double digit growth in a $2 billion market for simulation services, software, and anatomical models. We interview pioneers and leading edge practitioners of the art.

Find out how to respond when patients decline recommendations around virtual care. The AMC PSO patient safety alert, called Informed Patient Refusal in Virtual Care, includes a review of likely malpractice allegations and contributing factors. Safety Net interviews one of the co-authors, Dr. Adrienne Allen, Senior Director of Quality, Safety and Sustainability at North Shore Physicians Group Mass General Brigham Salem.

A new study shines light on nursing's role in malpractice claims and preventing diagnostic error. In 62 percent of the cases that involved a communication problem among providers, the patient died.

Micro-aggressions. Sexual harassment. Discrimination. On this episode of Safety Net, a special roundtable of health care experts looks at the legal and ethical dynamics behind conflicts over discrimination and harassment among colleagues and staff. What's happening in the Harvard medical system, as a national movement and local lawsuits press institutions to change?

Each year, thousands of misdiagnosed cancers, technical errors in surgery, and other harm events are added to a national database of medical malpractice claims, and a benchmarking report is released to the public. This year, instead of only describing the significance of the trends and numbers, the sponsoring organization from the Harvard system, Candello, is releasing a report that describes real stories of tangible change arising from those numbers.

Dr. Adam Schaffer is a hospitalist at Brigham and Women's Hospital in Boston and was the lead author of a study on the topic, which was published in the Journal of Hospital Medicine in June 2021. Dr. Schaffer is also Senior Clinical Analytics Specialist at CRICO. He joins us now to talk about this research.

Understanding its own risks and patient care vulnerabilities is vital to a health organization, but gaining that understanding is hard. Hospital leaders in the Harvard system are enthusiastic about outside risk assessments from CRICO, because the recommendations that come out are tangible, with no punitive component.