Narrow Results Clear All
- Communication Improvement 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 2
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
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.
Journal Article > Commentary
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.