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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...
Journal Article > Commentary
Dekker S. J Law Med Ethics. 2007;35:463-470.
The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2008;13:1-2.
This article contextualizes a recent news series on medication errors in community pharmacies, identifies important causes of errors not described in the series, and offers a broader perspective on the factors involved in pharmacy errors.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Rau J. Washington Post. February 12, 2012:A03.
This news article describes problems with analyzing data from a 2011 report on hospital-acquired conditions to accurately measure a hospital's overall quality of care.
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar.
Dublin, Ireland: Health Information and Quality Authority; October 2013.
This report presents results of an investigation into a hospital maternity service in Ireland, identifies numerous areas for improvement, and makes recommendations to enhance quality and safety.