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Save a brain, make a checklist

The Atlantic, March 18, 2014

On at least three occasions in 2007, surgeons at one Rhode Island hospital operated on the wrong side of their patients' heads. In one case, a resident neurosurgeon inserted a scalpel into the head of an 82-year-old patient. The surgeon noticed the error before reaching the skull and stitched up the wound, but the state health department fined the hospital $50,000. This sort of error is not terrifically rare. Based on malpractice judgments and out-of-court settlements for things like operating on the wrong side of a patient, or on the wrong patient, or leaving a sponge or other surgical object inside of a patient, researchers at Johns Hopkins estimate that such errors—called "never events" by hospital risk managers—occur not never, but more than 4,000 times in the U.S. every year.