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'Treat Systems, Not Errors,' Experts Say

Rebecca Voelker
JAMA. 1996;276(19):1537-1538. doi:10.1001/jama.1996.03540190009003.
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BETSY LEHMAN did not die in vain.

The death in March 1995 of the respected Boston Globe medical reporter of a cancer chemotherapy overdose at the renowned Dana-Farber Cancer Institute in Boston, Mass, sent shock waves through the medical community.

"That such a thing could happen at such a famous and well-regarded institution seemed incredible," says Lucian Leape, MD, adjunct professor of health policy at Harvard School of Public Health in Boston and an expert in medical errors. But Lehman's death was followed by a spate of highly publicized errors, including the amputation in Tampa, Fla, of a patient's healthy leg.

Speaking last month in Rancho Mirage, Calif, before a national meeting convened to seek ways to reduce medical errors, Leape said Lehman's death, more than any other single event, has galvanized the movement toward improved error reduction. "Our meeting here is proof that she did not die in vain."



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