COVID-19 Impact

You may see some delays in posting new content due to COVID-19. If you have any questions, please submit a message to PSNet Support.
 

PSNet: Patient Safety Network
Journal Article
Commentary

Wrong-site surgery.

Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318:2033-2034.

This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.