Preventable Errors

1 A patient is scheduled to have a bone spur removed from his right heel.; 2 A spinal surgery patient enters a facility for a right L4-5, L5-S1 widening laminectomy excise recurrent disc interbody fusion right.; 3 A female patient undergoes surgery to remove a small, pre-cancerous mass from her left breast.; 4 An elderly patient undergoing surgery on her left hip had the word "yes" written at the correct site, yet a plate and pin were implanted in the right hip.; Steps to safety; Accreditation; Accreditation Association; Adhesive; Ambulatory Health Care; American Academy; Association; Ben Taub General Hospital; C-arm; Care; Center; Commission; Commission International Center; Croteau; Croteau. Precise; Department; Development; Dr. Croteau. Precise; Florida's; Florida's Department; General Hospital; Health Care; Healthcare; Hospital; Houston, Texas. Ms. Marsh; International Center; JCAHO's Universal Protocol. Taking; Joint Commission; Joint Commission International Center; Jones; Marsh; Marsh. Steps; Medicine; Ms. Jones; Ms. Marsh; Ms. Marsh. Steps; Orthopaedic Surgeons; Precise; Protocol. Taking; Surgeons; Systems Development; Taking; Taub General Hospital; Texas. Ms. Marsh; Universal Protocol. Taking; Woodrum/Ambulatory Systems Development; X-ray; acceptable; accident; accomplished; acknowledges; action; active; actively; actual; adapted; addition; admits; affixed; alert; alerted; anesthesiologist; apparently; argues; arrival; arrives; arrow; asked; aspects; assists; assumed; attending; avoided; back; based; beginning; blood; bone; brought; burden; calling; cases; cautions; charge; checklist; clarification; clinical; coerced; comfortable; compare; completed; completes; complex; comply; confirm; confirmation; confirms; conflicting; considered; correct; count; covered; covers; create; decision; deeper; defense; delegate; describe; details; determined; differences; difficulties; directly; director; disc; discectomy; discuss; doctor; domineering; draped; draping; dressing; due; easily; easy; effective; elderly; encounters; endorsed; ends; ensure; ensuring; enters; equipment; error; evoke; examine; examples; excise; executive; exhibits; experts; explains; exposed; facility; fact; fail; failure; female; final; finds; foot; formulated; full; fully; fusion; healthy; hip; history; holds; hospital's; human; idea; identifies; identify; identifying; imaging; immediately; implanted; incalculable; inches; incident; incision; independently; industry; inevitable; information; initial; initiatives; ink; intended; interbody; investigate; investigation; involved; issues; labels; lack; laminectomy; leaving; left; licensing; listed; lot; lumbar; made; majority; make; management; manager; mark; marked; marking; mass; meant; meets; member; mention; mistake; mistook; neglected; notes; number; nurse; objected; observers; occur; offer; open-ended; operate; operating; organization; originally; oversee; overwhelming; paperwork; participants; participate; patient; percent; performed; personnel; physical; physically; physician; pin; plate; point; points; positioning; possibly; post; post-op; pre-cancerous; pre-op; pre-operative; pre-operatively; prepped; prepping; presence; present; president; prior; procedure; procedures; process; professional; proper; protocol; questions; radiographic; realizing; recommends; recurrent; redundantly; regularly; regulatory; relieves; remove; reports; required; requires; requiring; responsible; rests; revealed; risk; role; root; ruled; safe; safety; satisfactorily; scar; schedule; sees; services; share; should've; signature; silence; site; sites; situation; skin; source; speak; spinal; spur; staff; starts; state; steps; stopped; studied; sufficiently; suggests; surgeon; surgery; surgical; taking; targeted; team; temperature; thing; three-step; time; timeout; trust; type; undergoes; undergoing; verbally; verification; verified; verifying; views; visible; wakes; widening; witnessed; word; working; written; wrong; wrong-patient; wrong-procedure; wrong-site; years