Performing the Wrong Procedure is the first article in a new section of JAMA concentrating on performance improvement. This is a case report about a 90-year-old woman ho had a dialysis catheter mistakenly placed instead of a normal central line for antibiotic administration. Various options to correct the error are presented with a root cause analysis and the final outcomes of the case.
Minnier T, Phrampus P, Waddell L. Journal of the American Medical Association. 2016;316(11):1207-8. http://dx.doi.org/10.1001/jama.2016.9134 Access the full text via CIAP if you are an employee of NSW Health.
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