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International Journal for Quality in Health Care 14:259-260 (2002)
© 2002 International Society for Quality in Health Care

Every Defect is a Treasure

Breaks in care in the ambulatory care setting: the risks to patient safety

Kathleen Dwyer

Adapted with permission by Kathleen Dwyer, MS, from Resource, November 2001. Resource is an audiotape publication of the Risk Management Foundation of the Harvard Medical Institutions, Cambridge, MA, USA.

During a 14-month period of care, a healthy 50-year-old woman reports episodes of rectal bleeding to one and later to a second internist. Absence of steps taken either to substantiate a diagnosis of hemorrhoids or to ensure that a colonoscopy is carried out leads to fatal results.

A healthy 50-year-old teacher presents to her internist with a history of occasional bleeding from hemorrhoids over several years. The patient recalls being previously diagnosed with hemorrhoids during one . . . [Full Text of this Article]


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