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Cases & Commentaries
- Spotlight Case
- Web M&M
Eric S. Holmboe, MD; February 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
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...
Journal Article > Commentary
Baumrucker SJ. Am J Hosp Palliat Care. 2006;23:417-421.
This roundtable discussion provides legal, ethical, nursing, and medical perspectives on whether to disclose a misdiagnosis to the patient and their family after cancer has metastasized and death is imminent.
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.
ISMP Medication Safety Alert! Acute Care Edition. December 3, 2009;14:1-3.
This article discusses how a criminal prosecution has deeply affected an Ohio pharmacist who lost his license and is serving a prison sentence for failing to detect a medical error, which led to the death of a child.
ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.
This newsletter piece discusses the pros and cons of physicians dispensing medications and its impact on patient safety.
Greenberg P, Ranum D, Siegal D. Patient Saf Qual Healthc. October 2015;12:18-20,22-24.
Journal Article > Commentary
2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.
Neuss MN, Gilmore TR, Belderson KM, et al. J Oncol Pract. 2016;12:1262-1271.
Administration errors involving chemotherapeutic agents can result in patient harm. This set of standards provides guidance to help ensure reliable use of these high-alert medications for both adult and pediatric patients. Components of the revised standards are expanded to include two-person verification, vinca alkaloid mini-bag administration, and labeling enhancements for home-based chemotherapy.
Journal Article > Study
Aaronson EL, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019 Jul 23; [Epub ahead of print].
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.