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Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.
Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

Using a case report, the authors discuss a series of errors and illustrate the concepts of active and latent failures. They suggest systems-oriented improvements to both the technique and catheter kit used.
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