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RISK MANAGEMENT PUBLICATION

Communication Failures That Cause Surgical “Never Events”

April 2019

This article addresses three of the events associated with surgery: retained surgical items, surgical fires, and wrong-site surgery. All three events are rare in relation to the enormous number of surgeries performed every year in the US.

CASES ONE - FOUR
Unintended Retained Surgical Items

CASES FIVE - SEVEN
Surgical Fires

CASE EIGHT 
Wrong-Site Surgery

 

April 2019
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