Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

T. E. Lum; Rollin J. Fairbanks; EC Pennington; Zwemer FL.

Commentary

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

July 13, 2005

Lum TE, Fairbanks RJ, Pennington EC, et al. Acad Emerg Med. 2005;12(7):658-662.

View more articles from the same authors.

Using a case report, the authors discuss a series of errors and illustrate the concepts of active and latent failures. They suggest systems-oriented improvements to both the technique and catheter kit used.

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Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

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