ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.
Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.
London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.
A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.