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- Communication Improvement 2
- Culture of Safety 1
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- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches 4
- Quality Improvement Strategies 3
- Technologic Approaches 2
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 2
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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 > Review
Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.
The authors analyze existing evidence on using intraoperative cholangiography (IOC) to minimize patient injury during laparoscopic cholecystectomy. They conclude that strong observational evidence supports the use of IOC.
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.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
Spiegel A. Morning Edition. National Public Radio. February 11, 2013.
McFadden C. ABC News Nightline. March 6, 2013.
Bernhard B. St. Louis Post-Dispatch. May 5, 2013:A10.
This newspaper article relates how medical mistakes affect both patients and clinicians and offers tips for patients and families to prepare for surgery.
Saul S. New York Times. July 19, 2010;A1.
This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the accuracy of pathology for early stages of disease and ductal carcinoma in situ has experts debating the best mechanisms to ensure competency and reliability in this field.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.