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

Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e247. doi: 10.1097/PTS.0000000000000846.

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June 23, 2021
Walters GK. J Patient Saf. 2021;17(4):e264-e267.

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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Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e247. doi: 10.1097/PTS.0000000000000846.