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- Communication Improvement 6
- Culture of Safety 2
- Education and Training 7
- Error Reporting and Analysis 7
- Human Factors Engineering 2
- Legal and Policy Approaches 9
- Logistical Approaches 2
- Quality Improvement Strategies 6
- Teamwork 1
- Technologic Approaches 3
- Transparency and Accountability 1
- Device-related Complications 3
- Diagnostic Errors 10
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 2
- Medical Complications 1
- Medication Safety 5
- Nonsurgical Procedural Complications 2
- Surgical Complications 2
- Allied Health Services 1
- Nursing 2
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Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Journal Article > Study
Rohrer JE, Esler WV, Saeed Q, et al. Support Care Cancer. 2006;14:871-873.
This survey of community cancer center patients found that approximately 70% misunderstood the meaning of do-not-resuscitate (DNR).
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Journal Article > Study
Weingart SN, Simchowitz B, Kahlert Eng T, et al. Jt Comm J Qual Patient Saf. 2009;35:63-71.
This study combined two approaches widely advocated for improving safety: teamwork training and involving patients in safety efforts. In response to prior research on safety problems in outpatient chemotherapy suites, the investigators implemented a teamwork training intervention with the assistance of patient volunteers. Based on safety principles such as situational awareness and closed-loop communication, the intervention focused on encouraging patients to ask specific questions regarding their care. Patients who were aware of the program reported that they changed their behaviors as a result. This is one of the first studies to report on engaging patients in a teamwork intervention.
Bogdanich W. New York Times. June 20, 2009;National Desk:1.
Flawed safety standards, including a lack of peer review and oversight, led to a series of errors in a cancer unit at a Philadelphia Veterans Affairs hospital.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Tools/Toolkit > Fact Sheet/FAQs
Fairfax, VA: The American Society for Radiation Oncology; March 9, 2010.
This Web site offers information to help patients understand both safety issues and risks involved in radiation therapy.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
This Web site provides resources for patients and practitioners to help reduce risk of infection during outpatient chemotherapy.
Simons A. Star Tribune. January 4, 2012:1A.
This newspaper article describes how a delay in diagnosis resulted in minimal chance of survival and discusses legal issues surrounding the case.
Willams B. The Record. March 10, 2012.
Exploring how drug shortages affect patients, this news piece describes one cancer patient's efforts to acquire the chemotherapeutic agent that is prolonging his life.
Gupta S. CNN. July 23, 2012.
This news video reports on how drug shortages affect patients and describes US Food and Drug Administration (FDA) efforts to address the issue.
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.
London, England: Teenage Cancer Trust; 2013.
This report spotlights challenges to early diagnosis of cancer in pediatrics and offers guidance for clinicians and families to improve care for these patients.
Gubar S. New York Times. January 2, 2014.
Patients and physicians can both miss warning signs of cancer. This newspaper article reports on diagnostic errors involving cancer—including common causes and patients' experiences—and emphasizes the serious consequences of misdiagnosing this condition.
Olsen D. State Journal-Register. June 26, 2011.
This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Journal Article > Study
Wolf JA, Moreau J, Akilov O, et al. JAMA Dermatol. 2013;149:422-426.
Smartphones provide opportunities to share information and may become invaluable tools for certain health care functions, such as assisting smoking cessation or monitoring medication adverse effects. Recently, several mobile health care applications have been developed and marketed directly to non-clinician consumers. This study evaluates the accuracy of four smartphone applications intended to assess photographs of skin lesions to help users decide whether the lesion is potentially dangerous. Overall, the applications performed poorly, with three incorrectly classifying 30% or more of melanomas as unconcerning. In the more accurate fourth application, images are sent to a board-certified dermatologist for evaluation, rather than using a preset algorithm. The concern is that reliance on these dermatologic applications could delay diagnoses and ultimately harm patients.
Beck M. Wall Street Journal. September 14, 2014.
Overdiagnosis has emerged as a patient safety issue. Reporting on how the push for early identification of cancer has led to screening, detection, and treatment of tumors that may never cause harm, this newspaper article discusses the impact of unnecessary tests and treatment on patients and health systems. Researchers are working to design better tests to distinguish between benign abnormalities and cancers.
Carville O. The Star. November 14, 2014.
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.