Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

@article{Lum2005ProfilesIP,
  title={Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.},
  author={Timothy E Lum and Rollin J. Fairbanks and Elliot C. Pennington and Frank L. Zwemer},
  journal={Academic emergency medicine : official journal of the Society for Academic Emergency Medicine},
  year={2005},
  volume={12 7},
  pages={658-62}
}
This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and… CONTINUE READING

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