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Cases & Commentaries
- Web M&M
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Journal Article > Study
Duthie EA. J Patient Saf. 2010;6:108-114.
This study examines five wrong-procedure cases by applying James Reason's human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.
Journal Article > Commentary
Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318:2033-2034.
This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.