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Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit

Peter J. Pronovost, MD, PhD; Albert W. Wu, MD, MPH; and J. Bryan Sexton, PhD
[+] Article, Author, and Disclosure Information

From The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and The University of Texas, Center of Excellence for Patient Safety Research and Practice, Texas.

Grant Support: By the Agency for Healthcare Research and Quality (grant number U18 HS11902). Funding for the Quality Grand Rounds series is supported by the California Healthcare Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peter J. Pronovost, MD, PhD, Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.

Current Author Addresses: Drs. Pronovost and Sexton: Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.

Dr. Wu: Johns Hopkins University, 624 North Broadway, Hampton House, Room 633, Baltimore, MD 21205.

Ann Intern Med. 2004;140(12):1025-1033. doi:10.7326/0003-4819-140-12-200406150-00013
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Quality Grand Roundsis a series of articles and companion conferences designed to explore a range of quality issues and medical errors. Presenting actual cases drawn from institutions around the United States, the articles integrate traditional medical case histories with results of root-cause analyses and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases do not come from the discussants' home institutions.

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Focused Analysis of Medical Errors
Posted on July 9, 2004
Kenneth K Kessler
University of Miami School of Medicine
Conflict of Interest: None Declared

TO THE EDITOR: Pronovost, Wu and Sexton (1) present an excellent in depth analysis of a medical error involving removal of a central line. Despite the value and increasing use of root cause analyses and system solutions to medical errors, it is often useful to determine the one person or circumstance that is "responsible" for the error, not to assess blame but rather to identify a focal point for future prevention. In this case the habit of dumping the "scut work" "“ routine removal of a catheter "“ on the least trained person appears to be pivotal. This seems lost in the analyses and "system factors" as summarized in the complexities of table 2. Clearly the person who assigned the first year fellow the task of removing the catheter without appropriate instruction is responsible. While system analyses may determine what fail-safes could have prevented inappropriate action and resultant harm, it is important to determine and specifically address the lynchpin of the system.


1. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025-1033.

Conflict of Interest:

None declared

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