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Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.
Dunn D. J Perianesth Nurs. 2006;21:317-28; quiz 329-31.
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Mitchell P, Nicholson CL, Jenkins A. Acta Neurochir (Wien). 2006;148:1289-92; discussion 1292.
The authors interviewed surgeons involved in wrong-site incidents and found that the errors of omission were primarily due to distractions in the operating environment.
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.