The Case Records of the Massachusetts General Hospital are one of the most hallowed traditions in the medical literature, having been published weekly in the New England Journal of Medicine for more than a century. In contrast to the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong surgical procedure. Presented by the surgeon himself, the article details the factors that led to the error, including production pressures, language barriers, and failure to perform a time out, and explores the ramifications of the error for the surgeon, the patient, and the institution.