The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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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