Case Questions:

1. Who or what caused the death of Betsy Lehman?
2. What was the Dana-Farber’s system for ensuring patient safety?
3. How should the Dana-Farber respond to the Globe story ofMarch 23, 1995?
4. What are the key issues that must be addressed in the first fewdays after the error was discovered?

How should the Dana-Farber reduce the risk of future errors?

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