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PSNet: Patient Safety Network
Journal Article

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. Journal of neurosurgery. 2010;113:461-73.

This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.