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Commentary

Wrong-site surgery.

Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery. JAMA. 2017;318(20):2033-2034. doi:10.1001/jama.2017.17177

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December 13, 2017
Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318(20):2033-2034.

This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.

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Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery. JAMA. 2017;318(20):2033-2034. doi:10.1001/jama.2017.17177