https://rmfcd2-prod.rmf.harvard.edu/Podcasts/MedMal-Insider-Home Podcast for MedMal Insider en-us CRICO CRICO 2026 taugello@rmf.harvard.edu (Tom Augello) jrose@rmf.harvard.edu (Jennifer Rose) no Medmal Insider MedMal Insider episodes jrose@rmf.harvard.edu Jennifer Rose https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2026/Entire-Team-Faulted-for-Poor-Fetal-Monitoring Expert review concluded that a more aggressive response to non-reassuring fetal heart rate tracings, such as a conversion to cesarean delivery, would have been appropriate. Coupled with a delay in the diagnosis and treatment of chorioamnionitis, the case was settled in the high range. Tue, 03 Mar 2026 12:00:00 EST Expert review concluded that a more aggressive response to non-reassuring fetal heart rate tracings, such as a conversion to cesarean delivery, would have been appropriate. Coupled with a delay in the diagnosis and treatment of chorioamnionitis, the case was settled in the high range. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2026/FetalMonitoring.mp3 no 10:37 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2025/RN-Med-Error A patient died following a medication mixup in an understaffed medical ICU. A large settlement was reached on behalf of the RN who administered the wrong dose of the wrong medicine. Mon, 12 Jan 2026 05:00:00 EST A patient died following a medication mixup in an understaffed medical ICU. A large settlement was reached on behalf of the RN who administered the wrong dose of the wrong medicine. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2025/RNMedError.mp3 no 8:13 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2025/Timing-Tricky-in-Age-Discrimination After an employee alleges age discrimination, conversations with their supervisor could be perceived as retaliation. An attorney at CRICO describes the pitfalls in these discrimination and retaliation cases and how to avoid some of them. Mon, 24 Nov 2025 12:00:00 EST After an employee alleges age discrimination, conversations with their supervisor could be perceived as retaliation. An attorney at CRICO describes the pitfalls in these discrimination and retaliation cases and how to avoid some of them. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2025/EPLAgeCourtney.mp3 no 14:31 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2025/Communication-Post-op-Blamed-in-Large-Settlement A cholecystectomy patient alleged that mishandling of her post-operative calls to the surgical practice and lack of follow-up caused her post-operative complications. Like many cases, how the surgical practice communicated with the patient after a complication occurred was a key aspect. Wed, 02 Jul 2025 12:00:00 EST A cholecystectomy patient alleged that mishandling of her post-operative calls to the surgical practice and lack of follow-up caused her post-operative complications. Like many cases, how the surgical practice communicated with the patient after a complication occurred was a key aspect. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2025/Post-Surgery-Communication-Flawed.mp3 no 15:28 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2025/Battery-in-Nose Parents alleged that a delayed diagnosis of a foreign body in their child’s nose caused preventable nosebleeds, nasal infection, nasal septal perforation, and the need for surgery. The malpractice claim named the pediatric group, two pediatricians, and a pediatric nurse practitioner, and was settled in the low range. Fri, 28 Mar 2025 12:00:00 EST Parents alleged that a delayed diagnosis of a foreign body in their child’s nose caused preventable nosebleeds, nasal infection, nasal septal perforation, and the need for surgery. The malpractice claim named the pediatric group, two pediatricians, and a pediatric nurse practitioner, and was settled in the low range. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2025/BatteryInNose.mp3 no 15:09 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2024/Bad-Finger-Good-Documentation A patient sued her hand surgeon, claiming the surgical approach increased the chance that their finger wouldn’t fully heal from a prior fracture. The defense leaned on contemporaneous clinical notes and documentation of the consent process to achieve a defense verdict. Sat, 30 Nov 2024 05:00:00 EST A patient sued her hand surgeon, claiming the surgical approach increased the chance that their finger wouldn’t fully heal from a prior fracture. The defense leaned on contemporaneous clinical notes and documentation of the consent process to achieve a defense verdict. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2024/DocumentationCase.mp3 no 7:55 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2024/Tests-Pending-at-Discharge A 68-year-old male was admitted to the hospital after falling on ice and feeling short of breath. Two days after discharge, the patient arrived by ambulance at another hospital in septic shock. The patient filed a claim against the hospital, alleging that the failure to communicate a critical lab result required readmission and several weeks of follow-up treatment. Mon, 22 Jul 2024 12:00:00 EST A 68-year-old male was admitted to the hospital after falling on ice and feeling short of breath. Two days after discharge, the patient arrived by ambulance at another hospital in septic shock. The patient filed a claim against the hospital, alleging that the failure to communicate a critical lab result required readmission and several weeks of follow-up treatment. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2024/Tests-Pending-At-Discharge.mp3 no 11:26 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2024/OD-in-Labor-and-Delivery-Pushes-Change A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery unit. She was given the wrong drug and required an emergent C-section. The “five rights” of medication administration focuses on individual factors and not necessarily on system flaws. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, and focuses on psychological safety and promoting a non-punitive reporting culture. Tue, 14 May 2024 12:00:00 EST A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery unit. She was given the wrong drug and required an emergent C-section. The “five rights” of medication administration focuses on individual factors and not necessarily on system flaws. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, and focuses on psychological safety and promoting a non-punitive reporting culture. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2024/OBWrongDrug.mp3 no 6:38 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2023/Incidental-Finding A patient was imaged for abdominal pain, but the radiologist saw and reported an incidental finding of a nodule on the lower lung that was not pursued or revealed to the patient for 2 years. The cancer had metastasized, and the patient died from lung cancer 18 months later. Sat, 30 Dec 2023 12:00:00 EST A patient was imaged for abdominal pain, but the radiologist saw and reported an incidental finding of a nodule on the lower lung that was not pursued or revealed to the patient for 2 years. The cancer had metastasized, and the patient died from lung cancer 18 months later. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2023/IncidentalFinding.mp3 no 12:53 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2023/Overdose-or-Poor-Documentation The patient’s family alleged that improper management of the patient under anesthesia resulted in cardiorespiratory arrest, permanent brain damage, and a persistent vegetative state. While the cause of the patient’s cardiac arrest is uncertain, the CRNA failed to note which medications and doses were administered during the procedure, and the case was settled for more than $1 million. Tue, 17 Oct 2023 12:00:00 EST The patient’s family alleged that improper management of the patient under anesthesia resulted in cardiorespiratory arrest, permanent brain damage, and a persistent vegetative state. While the cause of the patient’s cardiac arrest is uncertain, the CRNA failed to note which medications and doses were administered during the procedure, and the case was settled for more than $1 million. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2023/Overdose.mp3 no 9:51 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2023/Response-to-Charges-of-Discrimination-can-Help-or-Hurt When hospitals and medical practices face charges of discrimination from employees, the consequences can include litigation, large payments, morale problems, and less quality care for the patients they serve. How an employer responds can make all the difference in outcomes. Based on closed claims in the Harvard medical system, two cases illustrate that point. We interview Megan Kures, of Hamel, Marcin, Dunn, Reardon and Shea, who offers some principles to follow. Wed, 12 Jul 2023 12:00:00 EST When hospitals and medical practices face charges of discrimination from employees, the consequences can include litigation, large payments, morale problems, and less quality care for the patients they serve. How an employer responds can make all the difference in outcomes. Based on closed claims in the Harvard medical system, two cases illustrate that point. We interview Megan Kures, of Hamel, Marcin, Dunn, Reardon and Shea, who offers some principles to follow. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2023/DiscriminationResponse.mp3 no 13:43 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2023/Missed-Endocarditis One thing that seemed to be missing in this particular evaluation was a formal differential diagnosis that may have been present in the physician’s brain, but wasn’t documented, and there’s no evidence that it was really thought about. Tue, 04 Apr 2023 12:00:00 EST One thing that seemed to be missing in this particular evaluation was a formal differential diagnosis that may have been present in the physician’s brain, but wasn’t documented, and there’s no evidence that it was really thought about. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2023/MissedEndocarditis.mp3 no 11:05 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2022/Bias-in-Accommodation Boston Attorney Megan Kures explains how a hospital should respond to a request for accommodation. Tip: it shouldn’t be a knee-jerk no, and be sure to involve HR from the start. Mon, 12 Dec 2022 05:00:00 EST Boston Attorney Megan Kures explains how a hospital should respond to a request for accommodation. Tip: it shouldn’t be a knee-jerk no, and be sure to involve HR from the start. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/PatientSafety/2022/Bias-in-Accommodation.mp3 no 11:35 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/New-Apology-Disclosure-Rules-Take-Effect-in-MA After a state medical error disclosure and apology law went into effect in November 2012, health providers in Massachusetts have protections and rules to follow. Tue, 27 Sep 2022 04:00:00 EST After a state medical error disclosure and apology law went into effect in November 2012, health providers in Massachusetts have protections and rules to follow. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/PatientSafety/2012/DisclosureLaw.mp3 no 7:35 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2022/Cardiac-Event-Mismanaged-in-ER An otherwise healthy 50-year-old woman presented to the Emergency Department with atypical chest pain. Discharge the next morning was followed by death. Wed, 13 Apr 2022 04:00:00 EST An otherwise healthy 50-year-old woman presented to the Emergency Department with atypical chest pain. Discharge the next morning was followed by death. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2022/CardiacEventMismanaged.mp3 no 11:39 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2021/Stroke-Untreated-in-ED The patient needed to be evaluated by a stroke team and a neurologist promptly to decide whether any treatment was indicated or possible. Triage should be the same whether the ER was empty or overcapacity. Tue, 16 Nov 2021 05:00:00 EST The patient needed to be evaluated by a stroke team and a neurologist promptly to decide whether any treatment was indicated or possible. Triage should be the same whether the ER was empty or overcapacity. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2021/StrokeCaseEinbinder.mp3 no 9:14 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2021/Surgical-Change-Needed-Consent The goal was to treat uncontrolled pain from tumors but the patient was left with unexpected hearing loss. The patient sued when she claimed the surgeon changed the side of the operation without consulting her. For ideas that might help prevent these negative outcomes, we talk with Douglas Smink, MD, MPH, an associate medical director for CRICO and the Chief of Surgery at Brigham and Women's Faulkner Hospital. Fri, 06 Aug 2021 04:00:00 EST The goal was to treat uncontrolled pain from tumors but the patient was left with unexpected hearing loss. The patient sued when she claimed the surgeon changed the side of the operation without consulting her. For ideas that might help prevent these negative outcomes, we talk with Douglas Smink, MD, MPH, an associate medical director for CRICO and the Chief of Surgery at Brigham and Women's Faulkner Hospital. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2021/SurgeryConsentforChange.mp3 no 10:47 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2021/Case-OB-Unit-Ill-prepared This OB patient’s risk factors were not adequately considered, and the team’s failure to follow protocols and secure back-up contributed to a lawsuit and a settlement of over $1 million. Wed, 02 Jun 2021 04:00:00 EST This OB patient’s risk factors were not adequately considered, and the team’s failure to follow protocols and secure back-up contributed to a lawsuit and a settlement of over $1 million. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2021/OBfailToPlan.mp3 no 9:32 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2021/Case-Discharge-Instructions-with-Carla-Oberst In a lawsuit naming the Emergency Medicine physician and a nurse, the patient alleged that a dressing was applied too tightly, compromising the circulation and resulting in a gangrenous foot, requiring amputation. Despite an eventual defense verdict, some lessons show how to prevent this bad clinical result and a five-year legal ordeal. Sun, 28 Feb 2021 05:00:00 EST In a lawsuit naming the Emergency Medicine physician and a nurse, the patient alleged that a dressing was applied too tightly, compromising the circulation and resulting in a gangrenous foot, requiring amputation. Despite an eventual defense verdict, some lessons show how to prevent this bad clinical result and a five-year legal ordeal. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2021/CaseDischargeInstruction.mp3 no 10:20 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Getting-Clinicians-in-Lawsuits-to-Care-for-Selves-is-Hard How a clinician is coping with the impact of being sued can be a significant factor in how effective he or she is as a defendant. But getting clinicians to accept help is often a challenge. Mon, 25 Jan 2021 05:00:00 EST How a clinician is coping with the impact of being sued can be a significant factor in how effective he or she is as a defendant. But getting clinicians to accept help is often a challenge. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/DefendantSupport.mp3 no 5:42 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2020/CaseHeparinRestartStrokeAdam Restarting heparin was not in the post-op instructions. In a lawsuit naming four physicians, the patient's estate alleged negligent failure to restart anticoagulation, resulting in a stroke and ultimately, her death. The case was settled for more than a million. Thu, 17 Dec 2020 05:00:00 EST Restarting heparin was not in the post-op instructions. In a lawsuit naming four physicians, the patient's estate alleged negligent failure to restart anticoagulation, resulting in a stroke and ultimately, her death. The case was settled for more than a million. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2020/CaseHepari-RestartAdam.mp3 no 10:17 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2020/Case-Young-Colon-CA-Patient Despite multiple visits to her PCP with similar complaints over years, this young patient did not get a timely diagnosis of colon cancer and died. Dr. Carla Ford looks at the testing, communication among providers, and some diagnostic insights for the next patient. Thu, 08 Oct 2020 04:00:00 EST Despite multiple visits to her PCP with similar complaints over years, this young patient did not get a timely diagnosis of colon cancer and died. Dr. Carla Ford looks at the testing, communication among providers, and some diagnostic insights for the next patient. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2020/CarlaYoungColonCA.mp3 no 7:56 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2020/Case-What-Else-Could-This-Be-Missed-PE A fatal PE misdiagnosis may have gone wrong from the very beginning. With analysis based on closed claims in the Harvard medical system, urgent care specialist Jonathan Einbinder explores ways an ordinary case with a tragic outcome might be prevented in the future. Mon, 20 Jul 2020 04:00:00 EST A fatal PE misdiagnosis may have gone wrong from the very beginning. With analysis based on closed claims in the Harvard medical system, urgent care specialist Jonathan Einbinder explores ways an ordinary case with a tragic outcome might be prevented in the future. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2020/caseembolismEinbinder.mp3 no 14:06 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2020/Case-Retained-Object-Adam-Schaffer The patient sued his oncologist and the hospital, claiming they mismanaged his post-op recovery when a stent was left behind for a year, leading to complications that required additional surgery. Thu, 02 Apr 2020 04:00:00 EST The patient sued his oncologist and the hospital, claiming they mismanaged his post-op recovery when a stent was left behind for a year, leading to complications that required additional surgery. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2020/retainedobjectAdamS.mp3 no 9:16 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2020/Case-Pedi-Family-communication In this case, a pediatric practice struggled to satisfy the family of a boy after two years of appropriate primary care. What did they learn about communicating with patients and their families over routine medical matters? Thu, 27 Feb 2020 05:00:00 EST In this case, a pediatric practice struggled to satisfy the family of a boy after two years of appropriate primary care. What did they learn about communicating with patients and their families over routine medical matters? https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2020/Unsatisfied-patient-family.mp3 no 8:30 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2019/Status-Change-Unrecognized In this case, communication between the primary provider and a phone consultant needed more clarity. Changes in the patient’s status needed a stronger response if a tragic outcome had any chance of being averted. Mon, 23 Dec 2019 05:00:00 EST In this case, communication between the primary provider and a phone consultant needed more clarity. Changes in the patient’s status needed a stronger response if a tragic outcome had any chance of being averted. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2019/ProlongedSecondStage.mp3 no 11:07 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2019/Slips-and-Falls-Case-Adam-S In this closed Harvard malpractice case, a patient fell during a radiology study because her risk status wasn’t communicated from the unit effectively. Hospitalist Adam Schaffer, MD, MPH, analyzes what went wrong and suggests some effective practices to prevent severe injury in places you don’t expect, with eyes on the patient. Thu, 16 May 2019 04:00:00 EST In this closed Harvard malpractice case, a patient fell during a radiology study because her risk status wasn’t communicated from the unit effectively. Hospitalist Adam Schaffer, MD, MPH, analyzes what went wrong and suggests some effective practices to prevent severe injury in places you don’t expect, with eyes on the patient. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2019/AdamSlipandFall.mp3 no 10:49 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2019/ICU-Case In this case, a 75-year-old female was admitted to the ICU with respiratory failure. A misplaced feeding tube led to her death. ICU intensivist Dr. Laura Myers discusses lessons from this case about supervision and assessing a provider's competence with a new procedure. Mon, 08 Apr 2019 04:00:00 EST In this case, a 75-year-old female was admitted to the ICU with respiratory failure. A misplaced feeding tube led to her death. ICU intensivist Dr. Laura Myers discusses lessons from this case about supervision and assessing a provider's competence with a new procedure. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2019/PodcastCaseStudyICUFeedingTube.mp3 no 9:35 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2018/Doctors-Lose-Cases-for-Themselves The defendant’s role in a successful defense against a claim of malpractice is critical, but it isn’t easy. Clinician have to be able to follow advice from lawyers, cope with their own emotions, which often include anger or fear, and project competence and likability to potential jurors. These things—none of which are taught in medical school—can be a challenge to a medical professional. Sometimes malpractice cases have to be settled because the defendant clinician cannot adapt to the legal system. Tue, 14 Aug 2018 04:00:00 EST The defendant’s role in a successful defense against a claim of malpractice is critical, but it isn’t easy. Clinician have to be able to follow advice from lawyers, cope with their own emotions, which often include anger or fear, and project competence and likability to potential jurors. These things—none of which are taught in medical school—can be a challenge to a medical professional. Sometimes malpractice cases have to be settled because the defendant clinician cannot adapt to the legal system. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2018/DoctorsLoseOwnCases.mp3 no 5:43 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2018/Closing-the-Loop-1 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. Mon, 16 Apr 2018 04:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/PatientSafety/2018/Closing-the-Loop-Final-Mix.mp3 no 13:04 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2017/Looking-for-a-System-Fix-After-Patient-Dies 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. Fri, 22 Dec 2017 05:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2018/npoPodAdamS.mp3 no 10:01 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2017/Young-ED-Heart-Attack 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? Mon, 20 Nov 2017 05:00:00 EST 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? https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2017/EDYoungHeartAttack.mp3 no 9:48 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2017/Pedi-Phone-Case 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. Mon, 11 Sep 2017 04:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2017/PediPhone.mp3 no 11:16 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2017/Oxy-Suicide-Case 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. Tue, 01 Aug 2017 04:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2017/OxySuicideCase.mp3 no 12:39 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2017/Case-Where-Culture-Helped-and-Hurt 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. Tue, 28 Feb 2017 05:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2017/BarbaraSzeidlerPodcast2017.mp3 no 7:21 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Case-Pedi-Celiac-DX 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. Fri, 23 Dec 2016 05:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/PediCeliac.mp3 no 8:52 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Missed-MI 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.” Thu, 01 Sep 2016 04:00:00 EST 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.” https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/MissedMIwithHistory.mp3 no 7:00 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Case-OB-Distraction 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. Wed, 20 Jul 2016 04:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/OBDistraction.mp3 no 7:02 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Mind-the-Gaps 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. Wed, 20 Jul 2016 04:00:00 EST 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. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Mind4.mp3 no 9:53 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Case-Study-Stroke The crux of the case is that a detailed history and physical exam were not performed, and so a broad differential was not considered before the patient suffered a stroke. Tue, 17 May 2016 04:00:00 EST The crux of the case is that a detailed history and physical exam were not performed, and so a broad differential was not considered before the patient suffered a stroke. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/StrokeCase.mp3 no 8:02 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2016/Case-Study-Urology In this case, we see issues that can arise in care that takes place across multiple institutions and providers, especially when the patient is self-referring. This patient was left with seriously-impaired kidney function, and he alleged a delay in diagnosis. Joining us is Dr. Carla Ford, who reviews medical malpractice claims for CRICO. Tue, 02 Feb 2016 05:00:00 EST In this case, we see issues that can arise in care that takes place across multiple institutions and providers, especially when the patient is self-referring. This patient was left with seriously-impaired kidney function, and he alleged a delay in diagnosis. Joining us is Dr. Carla Ford, who reviews medical malpractice claims for CRICO. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/CarlaTomUrologyCase.mp3 no 9:11 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2015/Case-Study-Spinal-Surgery This review of a closed malpractice claim shows the risks when communication before, during, and after a surgical complication goes awry. Wed, 02 Sep 2015 04:00:00 EST This review of a closed malpractice claim shows the risks when communication before, during, and after a surgical complication goes awry. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/SpinalSurgery.mp3 no 9:52 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2015/Case-Study-Lung-Nodule After a referral visit to a pulmonologist to follow up on a worrisome CT, none of the three parties—the PCP, the patient, and the pulmonologist—ever addressed the issue of the lung nodule again. The patient saw her primary care doctor several times for check-ups and minor issues over the next several years. The patient never returned to see the pulmonologist, and was not explicitly told by either doctor that she might have cancer. Four years after her visit with the pulmonologist, the patient became symptomatic from lung disease and was found to have inoperable cancer, metastatic to cervical spine. She died within months of her diagnosis. Thu, 07 May 2015 04:00:00 EST After a referral visit to a pulmonologist to follow up on a worrisome CT, none of the three parties—the PCP, the patient, and the pulmonologist—ever addressed the issue of the lung nodule again. The patient saw her primary care doctor several times for check-ups and minor issues over the next several years. The patient never returned to see the pulmonologist, and was not explicitly told by either doctor that she might have cancer. Four years after her visit with the pulmonologist, the patient became symptomatic from lung disease and was found to have inoperable cancer, metastatic to cervical spine. She died within months of her diagnosis. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/3Carla-Lung-Cancer.mp3 no 8:49 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2015/Case-Study-Breast-Cancer During an initial physical for a new 38-year-old female patient, the PCP noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Then she presented with a self-identified lump, followed by a cancer diagnosis. Dr. Carla Ford discusses the patient safety and risk management implications. Tue, 03 Mar 2015 05:00:00 EST During an initial physical for a new 38-year-old female patient, the PCP noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Then she presented with a self-identified lump, followed by a cancer diagnosis. Dr. Carla Ford discusses the patient safety and risk management implications. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/CaseBreastCancer2015.mp3 no 8:46 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2014/Case-Asplenic-Sepsis Despite multiple visits to her PCP, a 30-year-old woman without a spleen was never given prophylactic antibiotics or told the risks of a high fever. A mishandled telephone triage delayed her trip to the ER, and the resulting pneumococcal sepsis led to permanent disabilities and a $1 million-plus settlement. Tue, 25 Mar 2014 04:02:00 EST Despite multiple visits to her PCP, a 30-year-old woman without a spleen was never given prophylactic antibiotics or told the risks of a high fever. A mishandled telephone triage delayed her trip to the ER, and the resulting pneumococcal sepsis led to permanent disabilities and a $1 million-plus settlement. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Asplenic-Case-Rich-Parker-final.mp3 no 6:17 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2013/Missed-Steps-Delay-Breast-Diagnosis Even though the patient identified a lump on her breast, it took more than a year to diagnose cancer. Family history-taking and proper imaging were lacking. CRICO interviews one of the authors of a Harvard breast care management algorithm, Michelle Specht, MD, to consider how following such a guideline could have helped the gynecologist and radiologist—and ultimately the patient. Thu, 31 Oct 2013 04:00:00 EST Even though the patient identified a lump on her breast, it took more than a year to diagnose cancer. Family history-taking and proper imaging were lacking. CRICO interviews one of the authors of a Harvard breast care management algorithm, Michelle Specht, MD, to consider how following such a guideline could have helped the gynecologist and radiologist—and ultimately the patient. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Breast-CaseSpecht.mp3 no 10:07 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2013/A-Missed-MI-Diagnosis-and-Death-After-Office-Visit As in many missed MI cases, the primary care physician did not order an EKG. Thomas Sequist, MD, of Atrius Health, describes where some of these cases typically go wrong, and how using a Framingham Risk Score can help with the evaluation process in the office practice. Thu, 25 Jul 2013 04:00:00 EST As in many missed MI cases, the primary care physician did not order an EKG. Thomas Sequist, MD, of Atrius Health, describes where some of these cases typically go wrong, and how using a Framingham Risk Score can help with the evaluation process in the office practice. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/abstract-Sequist-MI.mp3 no 9:05 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2013/Misread-of-Data-Slowed-Response-Hurt-Patient Fetal heart rate tracings indicated earlier intervention after prolonged induction of labor. The obstetrician and nurse midwife were faulted for not working more closely together. Wed, 17 Apr 2013 04:00:00 EST Fetal heart rate tracings indicated earlier intervention after prolonged induction of labor. The obstetrician and nurse midwife were faulted for not working more closely together. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/MONO-FullSlow-Response-Rate.mp3 no 8:21 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2013/Patient-Loses-Finger-after-Medication-Error-in-ER Medication error in the ER was preventable. Culture and communication problems compounded an error that required several surgeries and amputation. Mon, 25 Feb 2013 05:00:00 EST Medication error in the ER was preventable. Culture and communication problems compounded an error that required several surgeries and amputation. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/3Finger-Amputation.mp3 no 10:04 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2013/Missed-MI-and-a-Failure-to-Connect-the-Dots Dr. Gordon Schiff discusses how to prevent a patient's heart attack, this practice would have needed better systems to monitor and identify chronic risk factors. Tue, 15 Jan 2013 05:00:00 EST Dr. Gordon Schiff discusses how to prevent a patient's heart attack, this practice would have needed better systems to monitor and identify chronic risk factors. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/MissedMIGordy.mp3 no 9:04 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/We-Blew-It A top surgeon mistakenly performed carpal tunnel instead of trigger release procedure after multiple interruptions and personnel shift changes in OR. Fri, 19 Oct 2012 04:00:00 EST A top surgeon mistakenly performed carpal tunnel instead of trigger release procedure after multiple interruptions and personnel shift changes in OR. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/FLV/Podcasts/Case-Studies/pod_ring.mp4 no 9:07 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/Late-Follow-Up-Miffed-Patient-in-1821-Ortho-Case Nation's “first malpractice crisis” resulted in 1821, after a horse fell on a man and the surgeon waited a month to visit his patient to see if his attempted hip reduction worked. Mon, 17 Sep 2012 04:00:00 EST Nation's “first malpractice crisis” resulted in 1821, after a horse fell on a man and the surgeon waited a month to visit his patient to see if his attempted hip reduction worked. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/2Firstmalpracticecrisis.mp3 no 9:10 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/Midwife-Didnt-Seek-OB-Consult-on-Fetal-Heart-Rate Lack of collaboration and poor documentation among the factors in large settlement with severely compromised infant. Tue, 31 Jul 2012 04:00:00 EST Lack of collaboration and poor documentation among the factors in large settlement with severely compromised infant. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/4pMidwifenoconsult.mp3 no 9:59 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/Bleed-Recovery-Good-But-Disclosure-Faulted The surgeon orchestrated a great recovery from a massive bleed that resulted in blindness, but the patient sued for answers. Fri, 01 Jun 2012 04:00:00 EST The surgeon orchestrated a great recovery from a massive bleed that resulted in blindness, but the patient sued for answers. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/p3bleed-event-discl-faulted.mp3?sc_lang=en&hash=1E4D49926A673DC60A4C9BD033679C34 no 8:25 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2012/Test-Delay-Blamed-in-Womans-Death The patient was under 50 and lack of communication between the PCP and GI about a sigmoidoscopy order contributed to a diagnostic failure. Mon, 09 Apr 2012 04:00:00 EST The patient was under 50 and lack of communication between the PCP and GI about a sigmoidoscopy order contributed to a diagnostic failure. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Test-Delay-Blamed-in-Womans-Colon-C.mp3?sc_lang=en&hash=071464DB3AF0609AA5346583F1AFB0C4 no 7:40 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2011/Retained-Object-Reliance-on-Memory-Harms-Patient The surgeon postponed removing a catheter fragment, and then forgot about it. Thu, 16 Jun 2011 04:00:00 EST The surgeon postponed removing a catheter fragment, and then forgot about it. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Retained-Object_-Reliance-on-Memory.mp3?sc_lang=en&hash=E1DCD2EEAA25AA8C5E1697D97452E7E3 no 8:30 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2011/Lack-of-Empathy-Triggers-Suit-Against-Surgeon The patient and his wife felt that the surgeon was not forthcoming with an explanation of what happened and seemed indifferent to the impact on his patient, following conversion to an open procedure and large blood loss. Thu, 03 Feb 2011 05:00:00 EST The patient and his wife felt that the surgeon was not forthcoming with an explanation of what happened and seemed indifferent to the impact on his patient, following conversion to an open procedure and large blood loss. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Lack-of-Empathy-Triggers-Suit-Agains.mp3 no 10:24 https://rmfcd2-prod.rmf.harvard.edu/Podcasts/2006/Wrong-Site-Quickly-Settled Clear liability case from a reversed X-ray was resolved efficiently with insurer/institution cooperation. Sat, 01 Jul 2006 04:00:00 EST Clear liability case from a reversed X-ray was resolved efficiently with insurer/institution cooperation. https://rmfcd2-prod.rmf.harvard.edu/-/media/Files/_Global/Audio/MP3s/podcasts/case/Abstract0607.mp3 no 8:09