Summary
Despite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised.
This study examined surgical never events occurring in hospitals in California and summarize recommendations to prevent future events.
Rates of serious surgical errors in California and plans to prevent recurrence (3 May 2021)
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2779420
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