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Cases & Commentaries
- Web M&M
Jeanne Mandelblatt, MD, MPH; February 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
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...
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert to bring attention to a rare but potentially severe administration error reported with the cancer drug vincristine. A previous editorial discusses similar errors.
Journal Article > Commentary
A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.
Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.
This article describes a structured approach to identify and address medical risks that might arise from changes in clinical practice.
Journal Article > Review
Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.
Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.
Journal Article > Commentary
Esserman L. JAMA Intern Med. 2016;176:888-889.
Biased physician recommendations can undermine safe, patient-centered care. This commentary and related perspective illustrate how unneeded treatment for breast cancer represents the problem of overdiagnosis and describe the subsequent harm to patients. The author suggests that physicians should provide patients with a range of treatment options along with their associated risks and benefits, consider patients' preferences, and encourage shared decision-making.