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The wrong patient.
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case and the institution’s
root cause analysis
, the authors identify 17 distinct errors that culminated in the procedure taking place. The authors discuss the role of the individual versus the system, the existing culture contributing to the error, and strategies to avoid similar errors in the future. This article is part of a special collection entitled “Quality Grand Rounds,” a series of articles published in the
Annals of Internal Medicine
that explores a range of quality issues and medical errors.
PubMed citation
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Physicians
Safety Target
Wrong Patient
Error Types
Active Errors
Latent Errors
Approach to Improving Safety
Root Cause Analysis
Origin/Sponsor
United States of America