Chest tube in the wrong place when urgency plays a tricks on us: a case report

Abstract

Introduction: Unfortunately, medical errors are and will always be frequent in clinical practice. Unfortunately, as this area can lead to repercussions for the medical team and the hospital, it is an understudied area regarding patient safety. Case presentation: The authors present a case of a 55-year-old male with a gunshot wound to his left chest; regretfully, the chest radiography was mislabeled and flipped. Due to this, misguided by the image, and even though the bullet hole was on the left chest, a 32 FR tube was placed on the right chest. After realizing the mistake, another chest tube was placed in the proper chest. Thankfully, the patient successfully recovered. Discussion: Any process in clinical practice can go wrong, from diagnosis to treatment. If an error goes unnoticed, it can lead to severe complications because the medical team often assumes that the lab or X-ray is rarely wrong. This, coupled with the fatigue of a night shift, can lead to severe complications if there is no thorough review of the patient before a procedure is performed. Conclusion: All patients should be reviewed in sufficient detail for reflection and discussion; this daily routine will allow us to overcome the urgency of treating the patient’s illness rather than incorrectly assessing a patient. There are no quick fixes for medical errors, yet many strategies are in place to prevent them from happening. Guidelines, safety nets, standardized protocols, and checklists are crucial elements that could help us in our practice.