356 Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety
نویسندگان
چکیده
منابع مشابه
Root Cause and Error Analysis
Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (c...
متن کاملroot cause and error analysis
error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. a root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. an important factor of an error occurrence is a root cause (c...
متن کاملroot-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety
errors prevention and patient safety in transfusion medicine are a serious concern. errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. to specify system vulnerabilities and illustrate the potential...
متن کاملCerebral Air Embolism Following Pigtail Catheter Insertion for Pleural Fluid Drainage
Pigtail catheter drainage is a common procedure for the treatment of pleural effusion and pneumothorax. The most common complications of pigtail catheter insertion are pneumothorax, hemorrhage and chest pains. Cerebral air embolism is rare, but often fatal. In this paper, we report a case of cerebral air embolism in association with the insertion of a pigtail catheter for the drainage of a pleu...
متن کاملRoot-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety.
Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential...
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ژورنال
عنوان ژورنال: Annals of Emergency Medicine
سال: 2019
ISSN: 0196-0644
DOI: 10.1016/j.annemergmed.2019.08.317