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The operating room is a complex, high-risk system where adverse events remain commonplace. Certain errors, including wrong-site surgery, a retained surgical item (RSI), or an operating room fire, have been termed never events, indicating these should be 100% preventable. Despite significant attention and prevention efforts, never events still occur. It is estimated that physicians operating on bilateral structures will have a 25% lifetime risk of performing wrong-site surgery and that 1 in 8000 inpatient operations will have an RSI.1,2 These events can lead to significant physical and psychological harm to patients. The consequences can also be severe for clinicians and institutions, including the profound psychological toll on involved clinicians, as well as the financial burden of medicolegal action and negative effects on professional reputation.3
Berger ER, Greenberg CC, Bilimoria KY. Challenges in Reducing Surgical “Never Events”. JAMA. 2015;314(13):1386–1387. doi:10.1001/jama.2015.12327
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