Wrong-site surgery, retained surgical items, and surgical fires : A systematic review of surgical never events is a paper published in JAMA Surgery examining 138 studies which looked at these events since 2004. The median rates were about 1.32 per 10,000 for retained surgical items and 0.9% per 100,000 procedures involving wrong-site surgery. There were many different causes for specific events, but miscommunication was a common theme in many.
Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye IM, Beroes JM, et al
JAMA Surgery. 2015 [epub]. http://dx.doi.org/10.1001/jamasurg.2015.0301. Contact your health library for the full text of the article.
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