Vivid and terrifying

"Eye surgeon’s error confounds boy’s parents. She mistakenly operated on the wrong one; lawsuit being mulled."
Read more at The Columbian.

"He underwent surgery to remove his right testicle. When he woke up, his left one was missing."
Read more at The Washington Post.

"Mix-up leads to surgical procedure on wrong baby."
Read more at CBS News.

In 2004, the Joint Commission introduced a Universal Protocol that provides guidelines for the fundamental elements of a WSS prevention protocol. The Universal Protocol includes requirements for marking of the surgical site, confirmation of patient identity, confirmation of the intended procedure, and review of these details among the surgical team during a final time-out immediately prior to the start of surgery.
 

While Sign your Site, Universal Protocol and WHO Surgical Safety Checklist guidelines are specific in content, form of implementation can vary widely across hospitals and surgery centers. Even when WSS prevention protocols are implemented, adherence to such protocols may not be consistent within a given system. These factors may help to explain why, although WSS seems entirely preventable, WSS continues to occur and has not declined since the implementation of the Universal Protocol. (James 2012) In fact, the number of events reported to the Joint Commission have trended upward since 2005, after the implementation of the Universal Protocol.