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Colin P. West, MD, PhD; January 2008
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
Journal Article > Study
Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.
Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215.
Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.