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- WebM&M Cases 1
- Perspectives on Safety 2
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- Audiovisual 8
- Book/Report 8
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- Newspaper/Magazine Article 48
- Special or Theme Issue 1
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- Press Release/Announcement 2
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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
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
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.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Greene L. St. Petersburg Times. June 15, 2006:A1.
This article reports on the death of a pregnant 18-year-old after an overdose of magnesium sulfate.
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.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
"The Early Show." CBS News Video. February 7, 2007.
This news video discusses the impact of apology on potential malpractice lawsuits and features a patient and her anesthesiologist discussing how apology helped them to overcome the psychological distress of medical error.
"The Colbert Report." Comedy Central. March 19, 2007.
Stephen Colbert interviews Dr. Jerome Groopman about diagnostic errors in medicine and his new book, "How Doctors Think."
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
"60 Minutes." CBS News Video. March 16, 2008.
This news video features an interview with Dennis and Kimberly Quaid discussing the dangers of medical errors in the context of a near fatal heparin overdose of their twin infants at Cedars-Sinai Medical Center.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
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.
May H. Salt Lake Tribune. June 26, 2009.
Web Resource > Multi-use Website
Crowley CF, Nalder E. New York, NY: Hearst Digital News; August 2009.
This Web site provides access to numerous materials relating stories of medical harm and reporting data as well as contextual information from a news media investigation on medical errors.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
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.