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Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
Journal Article > Commentary
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.
The Case Records of the Massachusetts General Hospital are one of the most hallowed traditions in the medical literature, having been published weekly in the New England Journal of Medicine for more than a century. In contrast to the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong surgical procedure. Presented by the surgeon himself, the article details the factors that led to the error, including production pressures, language barriers, and failure to perform a time out, and explores the ramifications of the error for the surgeon, the patient, and the institution.