sábado, 16 de diciembre de 2017

Wrong-site surgery. | AHRQ Patient Safety Network

Wrong-site surgery. | AHRQ Patient Safety Network

PSNet email header



  • Commentary
  •  
  • Published November 2017

Wrong-site surgery.



    This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.








    View More

    No hay comentarios: