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Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-84.
Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially focused on procedural disciplines and operating room procedures. However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company database found that a significant proportion of WSPEs were committed by physicians in non-surgical fields (such as internal medicine). Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication errors the primary culprits. Interestingly, the injured patients did not file a malpractice lawsuit in the vast majority of cases. This study confirms and extends prior research showing that many WSPEs actually occur outside the operating room. The authors call for strict adherence to the Joint Commission Universal Protocol in order to prevent these never events.
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.