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Cases & Commentaries
- Web M&M
Colin F. Mackenzie, MD; March 2004
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
Perspectives on Safety > Perspective
with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.