Sorry, you need to enable JavaScript to visit this website.
Skip to main content
Commentary
Classic

The wrong patient.

Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.

Save
Print
June 14, 2011
Chassin MR, Becher EC. Ann Intern Med. 2002;136(11):826-833.
View more articles from the same authors.

This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case and the institution’s root cause analysis, the authors identify 17 distinct errors that culminated in the procedure taking place. The authors discuss the role of the individual versus the system, the existing culture contributing to the error, and strategies to avoid similar errors in the future. This article is part of a special collection entitled “Quality Grand Rounds,” a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.

Save
Print
Cite
Citation

Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.