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Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Commentary
Cohen M. Hosp Pharm. 2006;41:222-224.
This monthly selection of medication error reports provides examples of oral to IV dosing conflicts, name confusion with a new sleep aid, and radiology errors.