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Matthew B. Weinger, MD; George T. Blike, MD; September 2003
An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication.
Journal Article > Study
Garnerin P, Huchet-Belouard A, Diby M, Clergue F. Acta Anaesthesiol Scand. 2006;50:1114-1119.
The authors describe the systematic analysis of an incident involving inappropriate use of a medical device and discuss how their process for understanding and resolving the problem supported the safety culture in their organization.