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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 5
- Error Reporting and Analysis 7
- Human Factors Engineering 3
- Legal and Policy Approaches 6
- Quality Improvement Strategies 5
- Technologic Approaches 1
- Transparency and Accountability 1
- Device-related Complications 4
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 2
- Medication Safety 1
- MRI safety 1
- Nonsurgical Procedural Complications 5
- Surgical Complications 4
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McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.
This front page article in The New York Times reviews flying object incidents in magnetic resonance imaging (MRI) scanners. A number of dramatic cases are described (including several that were fatal), as are some of the challenges, both technological and procedural, in preventing this safety hazard.
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.
Landro L. Wall Street Journal (Eastern edition). December 23, 2008;D2.
Emphasizing the importance of safe device use to prevent patient harm, this article reports on the top 10 technology hazards in hospitals according to ECRI Institute's annual list, which includes alarm hazards, retained fragments, misleading displays, and surgical fires.
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.
Zarembo A. Los Angeles Times. October 15, 2009:A1.
This news piece describes communication gaps following a radiation overdose incident thought to involve more than 200 patients at one hospital.
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.
Tools/Toolkit > Fact Sheet/FAQs
Fairfax, VA: The American Society for Radiation Oncology; March 9, 2010.
This Web site offers information to help patients understand both safety issues and risks involved in radiation therapy.
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.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
McFadden C. ABC News Nightline. March 6, 2013.
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.
Spiegel A. Morning Edition. National Public Radio. February 11, 2013.
Bernhard B. St. Louis Post-Dispatch. May 5, 2013:A10.
This newspaper article relates how medical mistakes affect both patients and clinicians and offers tips for patients and families to prepare for surgery.
Journal Article > Commentary
Schroeder AR, Duncan JR. JAMA Pediatr. 2016;170:1037-1038.
Overuse of CT scans can expose patients to levels of radiation linked to increased rates of cancer. Describing efforts to raise awareness of problems associated with using medical imaging in children, this commentary calls for more targeted work to standardize the process for this population to reduce overuse to ensure safer care for pediatric patients.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.