TL;DR: Wrong-site surgery rarely happens because of one person–it happens when small errors, near misses, and unsafe cultures are ignored instead of learned from. This article caught my eye today, and it’s a change of pace to think about and write about mistakes other than my own (and I made more today — but healthcare mistakes are more important). Penn Medicine hospital cited over wrong-site surgery It’s a mistake to perform surgery on the wrong … Continue reading Learning from Mistakes in the Operating Room: Why Small Errors Lead to Big Harm