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PSNet: Patient Safety Network
Journal Article
Study

Wrong site surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN journal. 2009;90:215-8, 221-2.

This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.