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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...
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.
This article summarizes an incident involving chemotherapeutic agent overdose, describes factors contributing to the error, and provides recommendations for safer chemotherapy administration.