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Related Experiment Videos

Profiles in patient safety: sidedness error.

Marc J Shapiro1, Pat Croskerry, Steven Fisher

  • 1Department of Emergency Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, RI 02903, USA. mshapiro@lifespan.org

Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine
|April 3, 2002
PubMed
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A medical error occurred during a thoracentesis procedure when the physician operated on the wrong side, leading to respiratory distress. This case highlights the need for systemic improvements to prevent similar patient safety incidents.

Area of Science:

  • Medical Error Analysis
  • Patient Safety
  • Thoracic Medicine

Background:

  • A 45-year-old female presented with severe respiratory distress due to a left-sided pleural effusion.
  • An urgent thoracentesis was indicated to alleviate the respiratory compromise.

Observation:

  • A critical procedural error occurred during the thoracentesis.
  • The physician inadvertently performed the procedure on the incorrect side of the patient.

Findings:

  • The incident investigation revealed contributing factors related to human error and system vulnerabilities.
  • Analysis included common error types, human factors, and conditions conducive to medical mistakes.

Implications:

  • A systems-based approach is crucial for mitigating procedural errors in medicine.

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  • Educational strategies and enhanced protocols are recommended to improve patient safety and prevent future adverse events.