Scalia's death and the value of autopsy: a teachable moment.

Audiovisual

Scalia's death and the value of autopsy: a teachable moment.

April 6, 2016

Lundberg GD. Medscape. March 21, 2016.

View more articles from the same authors.

Although autopsies were previously considered an essential learning tool, their use has dramatically declined over time. Following a recent unexpected death of a high-profile individual, the author elucidates the instructive benefits of performing autopsies from determining cause of death to identifying diagnostic errors.

Available at

Related editorial

Related Resources From the Same Author(s)

The persistent problem of diagnostic error.

December 16, 2015

Will medicine ever become safer?

December 11, 2013

The War on Error: Common Diagnostic Errors.

March 8, 2017

Is misdiagnosis inevitable?

April 13, 2016

Conversations with...Lucian Leape, MD.

July 17, 2013

Cedars-Sinai doctors cling to pen and paper: transition to electronic medical records proves difficult.

April 3, 2005

Prioritizing Patient Safety Through Quality Measurement.

February 28, 2024

When a surgeon should just say 'I'm sorry'.

April 6, 2016

The Rebecca O'Malley Report.

May 21, 2008

Fatal mistakes.

March 30, 2016

Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.

May 11, 2016

Making Care Safer.

April 20, 2016

Most dangerous time at the hospital? It may be when you leave.

March 30, 2016

Bring back the autopsy.

March 16, 2016

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

April 3, 2013

Just a Cup of Tea – an Introduction to the SEIPS Framework.

May 24, 2023

When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

April 27, 2016

Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus.

April 10, 2024

A Conversation on Transparency and Patient Safety.

April 13, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.

March 3, 2021

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

May 4, 2016

COVID-19 dominates annual list of patient safety concerns.

March 24, 2021

Ability of practitioners to identify solid oral dosage tablets.

May 24, 2006

AHRQ announces interest in research on health IT safety.

February 11, 2015

Patient safety in the operating room.

September 21, 2023

Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color.

August 5, 2020

The Good, The Bad, and The Ugly: Patient Experiences with CRPs.

October 21, 2021 - October 21, 2021

MGH death spurs review of patient monitors.

March 3, 2010

The pain of wrong site surgery.

July 6, 2011

Hospitals tally their avoidable mistakes.

August 5, 2009

'Alarm fatigue’ a factor in 2nd death.

October 5, 2011

Sophisticated digital aids could help determine what ails you.

August 2, 2017

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

May 5, 2021

Healthcare Safety Investigations Conference 2022.

August 3, 2022

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

May 3, 2023

Tenfold errors can lead to tragedy.

September 6, 2006

"Near injury" alters procedures at Virginia Mason.

June 1, 2005

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

In redesigned room, hospital patients may feel better already.

September 3, 2014

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

July 5, 2023

PC standards for maternal safety.

September 11, 2019

Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems.

August 12, 2020

Incentives push more doctors to e-prescribe.

February 4, 2009

2015 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.

April 13, 2016

Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.

February 10, 2016

Coping and recovery in surgical residents after adverse events: the second victim phenomenon.

April 20, 2022

Improving patient care through improved caregiver support.

September 13, 2017

Misdiagnoses: a hidden risk of genetic testing.

November 16, 2016

Hospitals installed more sinks to stop infections. The sinks can make the problem worse.

November 9, 2016

Final Report of the Commission on Care.

August 3, 2016

Soaring numbers of 111 callers forced to wait for a call back.

February 10, 2016

Raising an alarm, doctors fight to yank hospital ICUs into the modern era.

September 21, 2016

Technical Series on Safer Primary Care.

January 11, 2017

Patient Safety 2015: Final Technical Report.

November 12, 2014

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

The Sunday story: when hospitals don't say sorry.

January 31, 2024

Building a case for medication reconciliation.

May 3, 2006

Five simple steps to avoid becoming a medical mystery.

December 14, 2016

Can computers help doctors reduce diagnostic errors?

December 21, 2016

CMPA Good Practices Guide.

March 8, 2017

America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016.

November 23, 2016

Reducing diagnostic errors.

October 19, 2016

When doctors get the wrong patient.

October 5, 2016

5 cataract surgeries, 5 people blinded: what went wrong?

August 24, 2016

Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.

June 1, 2016

Rating hospitals by the stars: the feds' latest plan to measure quality is the most controversial.

June 1, 2016

Hospital discharge: it's one of the most dangerous periods for patients.

May 11, 2016

Mean girls of the ER: the alarming nurse culture of bullying and hazing.

June 8, 2016

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

Balancing doctor egos and errors.

November 23, 2016

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

ECRI out with 10 deadly healthcare technology hazards for 2017.

November 23, 2016

Concurrent and Overlapping Surgeries: Additional Measures Warranted.

January 11, 2017

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance.

March 16, 2016

Another tragic parenteral nutrition compounding error.

May 11, 2011

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

A clinical reminder about the safe use of insulin vials.

March 6, 2013

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

Our long journey towards a safety-minded just culture. Part II: where we're going.

October 4, 2006

Nursing Home Antimicrobial Stewardship Guide.

November 9, 2016

An E.R. kicks the habit of opioids for pain.

December 14, 2016

Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project.

October 26, 2016

ASHP IV Adult Continuous Infusions.

January 18, 2017

Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition.

December 7, 2016

Sick children face potentially deadly danger: medication errors.

October 5, 2016

How to Improve Electronic Health Record Usability and Patient Safety.

October 5, 2016

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit.

May 25, 2016

'America's other drug problem': copious prescriptions for hospitalized elderly.

September 14, 2016

A better safety net for young doctors.

August 17, 2016

Many well-known hospitals fail to score high in Medicare rankings.

August 10, 2016

Using the web or an app instead of seeing a doctor? Caution is advised.

July 20, 2016

Medical misdiagnoses put pressure on patients to stay engaged.

September 21, 2016

Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine.

June 29, 2016

Hospitals that mess up are urged to confess.

June 22, 2016

Communicating Radiation Risks in Paediatric Imaging: Information to Support Healthcare Discussions About Benefit and Risk.

July 13, 2016

Improving doctor–patient communication in a digital world.

February 17, 2016

Drug shortages forcing hard decisions on rationing treatments.

February 10, 2016

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

Bringing the equity lens to patient safety event reporting.

October 25, 2023

Patient Safety Innovations

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

August 30, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patterns of error in interpretive pathology.

August 17, 2022

Nebraska Coalition for Patient Safety Annual Report.

May 1, 2022

Training Program for Nurses on Shift Work and Long Work Hours.

October 10, 2021

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

July 28, 2021

Perspectives on Safety

EMS Patient Safety in the Field

July 28, 2021

Interview

In Conversation With... James Augustine, MD

July 28, 2021

Some health workers suffering from addiction steal drugs meant for patients.

October 21, 2020

The slow, troubling death of the autopsy.

October 7, 2020

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error.

March 27, 2019

January 9, 2019

Diagnostic Excellence Initiative.

November 7, 2018

Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment.

December 6, 2017

Medical misdiagnosis: more common than you think.

November 15, 2017

Assessment of Reasoning Tool.

November 1, 2017

Curing our diagnostic disorder.

October 25, 2017

Comparison of clinical diagnoses and autopsy findings: six-year retrospective study.

October 18, 2017

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

May 17, 2017

Finding diagnostic errors in children admitted to the PICU.

February 8, 2017

War games and diagnostic errors.

January 18, 2017

Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module.

December 14, 2016

The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking.

November 16, 2016

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

Improving pathologists' communication skills.

September 14, 2016

Error disclosure in pathology and laboratory medicine: a review of the literature.

August 31, 2016

See More About The Topic

Hospitals

Health Care Executives and Administrators

Pathology and Laboratory Medicine

Diagnostic Errors

Epidemiology of Errors and Adverse Events