Performing the wrong procedure.
Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134.
Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.