Narrow Results Clear All
- Communication Improvement 9
- Education and Training 6
- Error Reporting and Analysis 13
- Human Factors Engineering 5
- Legal and Policy Approaches 21
- Quality Improvement Strategies 6
- Technologic Approaches 4
- Device-related Complications 3
- Diagnostic Errors 17
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 5
- Medical Complications 2
- Medication Safety 6
- Overtreatment 1
- Psychological and Social Complications 3
- Surgical Complications 12
- Transfusion Complications 1
- Allied Health Services 1
- Internal Medicine 13
- Nursing 3
- Palliative Care 1
- Pharmacy 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 7
- Health Care Providers 15
- Non-Health Care Professionals 8
Search results for ""
Cases & Commentaries
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
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.
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.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.
This article reports on a non-fatal medication error that involved several neonates (including the newborn twins of actor Dennis Quaid) receiving a concentration of heparin 1000 times higher than intended. The discussion includes current hospital efforts to prevent medication errors and the growing interest in use of bar coding technology. A similar error captured headlines in 2006 when it caused the deaths of three infants.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
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.
Youker M. KPTM.com; May 30, 2010.
This news piece reports on a fatal drug administration error in a child.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Messina I. Toledo Blade. August 24, 2012.
This newspaper article discusses an incident in which a transplant organ was mistakenly discarded.
Dwyer J. New York Times. October 25, 2012.
Ackerman T. Houston Chronicle. November 23, 2012.
This newspaper article describes challenges that may precipitate underdiagnosis or misdiagnosis of Alzheimer disease and conditions with similar presenting symptoms.
Agnvall E. AARP. November 16, 2012.
Saltzman W. ABC/WPVI. February 5, 2013.
Cohn J. The Atlantic. March 2013;311:59–67.
This magazine article reports how technology, such as IBM's Watson, can improve the efficiency and accuracy of health care decision making.