Performing the wrong procedure.

Tami Minnier; Paul Phrampus; Linda Waddell

Commentary

Performing the wrong procedure.

September 28, 2016

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316(11):1207-1208.

View more articles from the same authors.

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.

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Performing the wrong procedure.

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