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JAMA Performance Improvement
September 20, 2016

Performing the Wrong Procedure

Author Affiliations
  • 1University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134

A 90-year-old woman was admitted to the hospital with shortness of breath, a 3.15-kg weight gain since her last dialysis treatment, and a chest x-ray showing an infiltrate suggestive of pneumonia. Her physical examination revealed that she was alert and oriented to time, place, and person. A history of vancomycin-resistant enterococci required contact precautions. A do-not-resuscitate order was in her medical record.

When the patient was admitted, antibiotics were ordered for the suspected pneumonia. Central line placement was also ordered because intravenous access could not be obtained by the emergency department nursing staff. The patient was sent to the anesthesia department for line placement where a dialysis catheter was mistakenly placed instead of the conventional central line ordered.

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