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Cases & Commentaries
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C. Craig Blackmore, MD, MPH; March 2019
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Sentinel Event Alert. February 14, 2008;(38):1-3.
This alert provides risk reduction strategies and recommendations to minimize opportunities for failures associated with the use of magnetic resonance imaging (MRI).
Web Resource > Government Resource
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration. April 12, 2016.
This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.
Journal Article > Commentary
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.