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- Communication Improvement 1
- Culture of Safety 1
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
Search results for "Error Reporting"
- Chemotherapeutic Agents
- Error Reporting
- Internal Medicine
- Medication Errors/Preventable Adverse Drug Events
Journal Article > Study
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Franklin BD, Panesar SS, Vincent C, Donaldson LJ. BMJ Qual Saf. 2014;23:765-772.
Although there have been no reported accidental spinal injection of a vinca alkaloid in the United Kingdom since 2001, this study looked at upstream safety issues that could cause this fatal complication. The method used in this study provides a model for evaluating the resilience of safety practices, even in the absence of actual harmful events.
Journal Article > Study
Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.
Widely publicized errors associated with chemotherapy catalyzed extensive efforts to improve safety for patients receiving traditional intravenous chemotherapy. However, an increasing number of cancer patients are prescribed oral chemotherapy, and a prior study found that most cancer centers lack formal safety protocols for these medications. This AHRQ-funded analysis used multiple data sources to identify and characterize oral chemotherapy medication errors, and found that most errors resulted from dispensing incorrect dosages or medications—similar to prior studies of outpatient chemotherapy errors. The authors conclude that standardized safety practices for oral chemotherapy are urgently needed.
Journal Article > Commentary
Noble DJ, Donaldson LJ. Qual Saf Health Care. 2010;19:323-326.
Accidental administration of the intravenous chemotherapy agent vincristine into the sac around the spinal cord is almost invariably fatal. This error has been recognized since vincristine was first used in the 1960s and is now classified as a never event, but it has not been eliminated despite vigorous efforts. This article reviews the history of safety initiatives around vincristine and identifies five domains of failure, ranging from failure to adequately investigate cases to failure to translate safety solutions internationally. A fatal vincristine error that occurred in the United Kingdom was the subject of a detailed investigation commissioned by the National Health Service. One of this article's authors, Sir Liam Donaldson, was interviewed by AHRQ WebM&M in 2007.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
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...