title: Left arm/left leg lead reversals at the cable junction box: A cause for an epidemic of errors.
abstract: Medical errors, especially due to misinterpretation of electrocardiograms (ECG), are extremely common in patients admitted to the hospital and significantly account for increased morbidity, mortality and health care costs in the United States. Inaccurate performance of an ECG can lead to invalid interpretation and in turn may lead to costly cardiovascular evaluation. We report a retrospective series of 58 sequential cases of ECG limb lead reversals in the ER due to inadvertent interchange in the lead cables at the point where they insert into the cable junction box of one ECG machine. This case series highlights recognition of ECG lead reversal originating in the ECG machine itself. This case series also demonstrates an ongoing need for education regarding standardization of ECG testing and for recognizing technical anomalies to deliver appropriate care for the patient.
authors.affiliation: Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA.
authors.forename: Poonam
authors.initials: P
authors.lastname: Velagapudi
authors.affiliation: Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA.
authors.forename: Mohit K
authors.initials: MK
authors.lastname: Turagam
authors.affiliation: Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA.
authors.forename: Sherry
authors.initials: S
authors.lastname: Ritter
authors.affiliation: Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA. Electronic address: dohrmannm@health.missouri.edu.
authors.forename: Mary L
authors.initials: ML
authors.lastname: Dohrmann
mesh_terms: D001132:Arm; D002983:Clinical Competence / Q000706:statistics & numerical data*; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D004562:Electrocardiography / Q000295:instrumentation* / Q000706:statistics & numerical data*; D004566:Electrodes / Q000706:statistics & numerical data*; D004868:Equipment Failure / Q000706:statistics & numerical data; D006801:Humans; D007866:Leg; D008923:Missouri / Q000453:epidemiology; D012189:Retrospective Studies
keywords: ECG; Lead misplacement; Lead reversal; Medical errors