RT Journal Article SR Electronic T1 Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action JF Emergency Medicine Journal JO Emerg Med J FD BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine SP 260 OP 267 DO 10.1136/emermed-2015-204821 VO 33 IS 4 A1 Joshua S Broder A1 James W Fox A1 Judy Milne A1 Brent Jason Theiling A1 Ann White YR 2016 UL http://emj.bmj.com/content/33/4/260.abstract AB Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.