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Search results for "Latent Errors"
Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
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...