In this issue of JAMA Internal Medicine, Baker and colleagues1 present the case of a woman in her 90s who experienced fatal complications after implantation of a cardiac resynchronization therapy pacemaker (CRT-P). The authors make educational points in this Teachable Moment about the possible harms of placing a device in a high-risk patient with less than clear indications. There is, however, more we can learn from this story.
Varosy PD. Toward Improving Patient Safety: Systems-Based Approaches Are Our Best Way Forward. JAMA Intern Med. 2017;177(10):1514–1515. doi:10.1001/jamainternmed.2017.2987
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