Error by Distraction

An expert is a person who has made all the mistakes that can be made in a very narrow field. - Niels Bohr (1885–1962)

Although some medical errors are due to poor judgment or lack of knowledge, sometimes complications can occur even when operators know exactly what they are doing. Distraction by outside stimuli can cause even experienced operators to make basic errors. This case illustrates such a scenario.

• References

• 1 Harlal A, Ojha M, Johnston KW. Vena cava filter performance based on hemodynamics and reported thrombosis and pulmonary embolism patterns. J Vasc Interv Radiol 2007; 18 (1 Pt 1) 103-115
• 2 Kwok PC, Wong WK, Siu KW, Lai AK, Chan SC. Difficult retrieval of a retrievable inferior vena cava filter placed in an inverted orientation. J Vasc Interv Radiol 2006; 17 (1) 153-155
• 3 Goodell KH, Cao CG, Schwaitzberg SD. Effects of cognitive distraction on performance of laparoscopic surgical tasks. J Laparoendosc Adv Surg Tech A 2006; 16 (2) 94-98
• 4 Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg 2007; 246 (5) 705-711
• 5 Somville FJ, van Sprundel M, Somville J. Analysis of surgical errors in malpractice claims in Belgium. Acta Chir Belg 2010; 110 (1) 11-18