Surgical never events and contributing human factors.

  title={Surgical never events and contributing human factors.},
  author={Cornelius A Thiels and Tarun Mohan Lal and Joseph M Nienow and Kalyan S. Pasupathy and Renaldo C. Blocker and Johnathon M Aho and Timothy I Morgenthaler and Robert R. Cima and S. Hallbeck and Juliane Bingener},
  volume={158 2},
INTRODUCTION We report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS). METHODS From August 2009 to August 2014, operative and invasive procedural "Never Events" (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized… CONTINUE READING
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