Edited by Myron D. Fottler, Donna Malvey and Donna J. Slovensky
Chapter 3: High-reliability organizations
Since age 40 I have had an annual screening mammography, which is a radiological exam, intended to detect breast cancer. The facility where I get this exam is recognized by the American College of Radiology in the USA as having met the quality standards of its mammography accreditation program. Every year my experience is essentially the same: the test is scheduled, I arrive at the facility for the exam, which is efficiently performed, and a report of the negative results is mailed to me within a few days. A couple of years ago this scenario changed. After completing the routine exam I was contacted by the facility and told a suspicious spot had been found which required another exam, a breast ultrasound. Of course I was concerned and quickly scheduled the ultrasound. Upon arriving for the test, I was informed that an error had been made in the interpretation of my mammography results. When the written report was being created, a technician had entered the wrong results: a “key stroke” mistake they said. The exam findings should have been reported as negative. The ultrasound was cancelled and aside from a few days of significant apprehension about what might be my eventual diagnosis, and some inconvenience, thankfully no harm was done.
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