The PSNet Collection: All Content
Search All Content
Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.
Otolaryngol Head Neck Surg. 2018-2023.
Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472.
Although wrong-site surgeries are rare, they can be devastating to patients. One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful by both providers and patients.
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
Farnborough, UK: Healthcare Safety Investigation Branch; April 2021.