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A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.