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- Communication Improvement 3
- Culture of Safety 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 2
- Quality Improvement Strategies 4
- Technologic Approaches 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 1
- Psychological and Social Complications 1
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Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
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...
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.