The perfect storm: exam of a medical error and factors contributing to its possible escalation.

Gerald K Walters

Commentary

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

June 23, 2021

Walters GK. J Patient Saf. 2021;17(4):e264-e267.

View more articles from the same authors.

The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.

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The perfect storm: exam of a medical error and factors contributing to its possible escalation.

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The perfect storm: exam of a medical error and factors contributing to its possible escalation.

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Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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