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Never Events: Wrong Site Surgery In this case, a 93-year-old male patient presented at Grossmont Hospital in La Mesa, California, with bleeding on the left side of the brain on January 13, 2009. Surgery to remove the hematoma was required. However, an error occurred during the surgical process. Surgeon 1 marked the incorrect side of the patient’s head for surgery on January 16 without marking the head before that stage. In the operating room, Surgeons 1 and 2, the anesthesiologist, RNs 1 and 2, and the surgical technician conducted a time-out, verifying the correct site had been marked, and began the surgery. Only during the procedure did the team realize the mistake when they couldn’t find the bleeding. As a result, the patient had to undergo additional surgery on the correct (left) side, enduring extended time under anesthesia. RN 1 claimed to have read from the surgical consent three times during the time-out, stating that the surgery was to be on the left side. However, the surgical team failed to notice the surgeon’s marking error.
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