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Cases & Commentaries
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Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Journal Article > Study
Kelly JJ, Farley H, O'Cain C, et al. Jt Comm J Qual Patient Saf. 2011;37:285-288.
This survey of emergency medicine physician leaders found that more than 10% were unaware that the Universal Protocol, which requires a time-out before any invasive procedure, also applies to procedures performed in the emergency department.