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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...
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Abelson R. New York Times. April 2, 2007;National Desk section:1.
This article reports on physician-owned, mostly surgical specialty, hospitals that lack the ability to care for their patients who develop medical emergencies on site.
Journal Article > Commentary
Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.
This commentary compares two cases of preventable medical errors and suggests disclosure and remediation as tactics to establish post–adverse event trust with families and patients.
LaFraniere S. New York Times. April 19, 2015.
Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.
Estes A. Boston Globe. September 16, 2017.
Psychological safety can empower staff to communicate concerns that affect patient safety. This newspaper article reports on Veterans Affairs staff concerns about safety hazards, consequences whistle-blowers have faced after speaking up about problems, and efforts to protect whistle-blowers and improve the safety of the system.