EHR Routing Failure Leads to Delayed Cardiology Follow-Up

Case Study

An abnormal echocardiogram was not routed to the ordering clinician for review in the electronic health record, delaying timely cardiology follow-up and intervention before the patient experienced cardiac arrest and died.  



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Oct Case Study

Five CRICO Resources to Help Reduce Breast Cancer Malpractice Risk

October is Breast Cancer Awareness Month, and screening is only part of the picture. For physicians, recognizing concerning symptoms, choosing appropriate diagnostic evaluations, assessing risk, and communicating results are also essential for reducing patient harm and avoiding malpractice risk. 

These five CRICO resources offer scenarios to help strengthen your awareness, diagnoses, follow-ups, and the safe use of technology:

  1. Delayed Breast Cancer Diagnosis due to Automated EHR Report Error
    Highlights how EHR automation and test-result communication failures can delay breast cancer diagnosis, underscoring the need for routine, comprehensive reviews of templates and automated processes.
  2. Delayed Breast Cancer Diagnosis after Insufficient Follow-Up
    Underscores the importance of appropriately evaluating new breast complaints and following clinical guidelines, offering a practical patient-safety reminder for primary care physicians.
  3. CRICO Grant Spotlight: Breast Cancer Risk Assessment Among Women 40–49 in Primary Care
    This CRICO-funded project evaluated a personalized breast cancer risk report to support conversations between women in their 40s and their primary care physicians about mammography and prevention. It emphasizes risk assessment, shared decision-making, screening, and patient-physician communication.
  4. Breast Cancer Treatment Delayed 15 Months by Mishandled Radiology Report
    Demonstrates how fragmented records and gaps in communication and follow-up can leave a malignant pathology result unaddressed. It underscores the need for closed-loop tracking of orders and results.
  5. Bringing AI Into Medicine and Keeping It Safe
    This Safety Net podcast episode explores the risks of overreliance on AI. It highlights how computer-aided breast imaging can help detect cancers, but excessive trust in the technology may lead clinicians to miss findings they would otherwise recognize.
                           

Patient Safety Signals: General Medicine

Reliable test-result and referral management, mechanisms for reassessing unresolved symptoms, effective communication across care teams, and documentation of clinical reasoning can help address vulnerabilities before they contribute to patient harm and subsequent claims.

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October is Cybersecurity Awareness Month

Newsletter

Cybersecurity and Recovery

Related To: Communication,  Publications

CRICO Video


Surgery Risks & Patient Safety Playlist
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