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PSNet: Patient Safety Network
Journal Article
Study

Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.

Ryan A, Mohammad I, Murphy B. Pediatrics. 2006;117:236-8.

The authors present a case study of accidental intravenous breast milk administration to a premature infant. They discuss using both root cause analysis and a professional network to illustrate the value of finding systemic contributions to rare but potentially dangerous mistakes.