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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Quality Improvement Strategies 3
- Teamwork 1
- Transparency and Accountability 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
Thomas H. Gallagher, MD; May 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
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.
Journal Article > Study
Gallagher TH, Cook AJ, Brenner RJ, et al. Radiology. 2009;253:443-452.
Disclosing errors to patients does not happen consistently, as physicians in patient-care–oriented specialties (such as internal medicine and surgery) frequently "choose their words carefully" and fail to fully disclose errors when they occur. This survey of radiologists who regularly interpret mammograms found that three-quarters regularly discuss mammogram results directly with patients, but only a minority would disclose any information about an error in interpretation without prompting from the patient. Despite patients' clear preference for full disclosure of errors, only 15% of radiologists said they would discuss the specifics of the error and how it occurred. Errors in cancer diagnosis are a frequent cause of malpractice lawsuits, but in this study, having been sued was not associated with likelihood of disclosing an error. The study's lead author, Dr. Thomas Gallagher, was interviewed for AHRQ WebM&M in January 2009.
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.
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.
Journal Article > Commentary
Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.
This commentary describes strategies to improve safety in radiation oncology therapy.
Journal Article > Commentary
To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self-interest?
Berlin L. Radiology. 2013;268:4-7.