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Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Study
Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.
Taylor-Phillips S, Wallis MG, Jenkinson D, et al. JAMA. 2016;315:1956-1965.
Interpretation of mammograms is a repetitive task, and a vigilance decrement—decreased attention after many repetitions of the same task—could impair diagnostic accuracy. However, this large randomized trial found no evidence for vigilance decrement. Investigators also determined that radiologists were equally accurate at identifying abnormalities regardless of the order in which they reviewed the studies.