State health officials in Nassau County, New York, notified 628 patients in November 2007 that they should be tested for hepatitis and HIV. The testing was advised because they were treated by an anesthesiologist who used single syringes to draw from multiple-dose vials in a pain clinic and orthopedist's office,…

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Rhode Island Hospital's leadership team, in collaboration with independent consultants and expert physicians, is working to address processes that led to 3 wrong-site procedures in 2007. The hospital, located in Providence, was reprimanded and fined $50,000 by the state health department after the third incident, which occurred Nov 23. Two…

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No single step, whether the time out before the incision or surgical site marking, is adequate to prevent wrong surgery. Rather, site verification needs to be a package of activities that involves the team—the nurse, patient, surgeon, and anesthesia provider—as well as an accurate OR schedule and consent and a…

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The patient had come to the OR for joint replacement surgery. Though she had a complicated medical history, there was no reason to believe she would have serious problems. But during the surgery, things went wrong, and despite everyone's efforts, the patient died. It hit the team hard, including the…

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