Journal Article

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

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.