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- Communication Improvement
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering
- Legal and Policy Approaches 2
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Health Care Executives and Administrators 6
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 1
- Patients 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
C. Craig Blackmore, MD, MPH; March 2019
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
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...
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
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.
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.
This article examines a case in which a health care professional faces criminal charges for a medication error. The piece discusses how criminalization of errors in health care could thwart broader efforts to learn from mistakes.
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 > Study
Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6:e011394.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.