Archive

Please note that some links are available only to those on a Partners computer. Safety Matters was initially intended for BWH only, but issues since the middle of 2015 are now available publicly.

2017

January:  Medication Formulation Error Leads to Overdose

2016

October/November: Opioid Overdose by Visitor to BWH Ends Fatally

August/September: Communication Breakdown Leads to Patient Burn

June/July: Price-Checking of Prescriptions Results in Dangerous Combination of Medications

April/May: Medication Error Sparks Transformation of Clinic’s Patient Safety Culture

February/March: Safety Reporting Leads to Safer Systems

Speak up for your Safety: 5 Tips to be a Partner in Your Care

January: Breakdown in Medication Reconciliation Leads to Inpatient Dose 16 Times Higher Than Home Dose

2015

December: Delayed Diagnosis

June/July: Follow the Lines, One at a Time

August/September: Error Leads to Delayed Cancer Diagnosis

 

Archive on BWH intranet – issues from 2011 to 2015