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Report: Every other day, a near-miss occurs in Pennsylvania

Quality Improvement Monitor, June 29, 2007

A new report has found that every other day, a potential wrong-site surgery is caught in a Pennsylvania Hospital, according to the Philadelphia Inquirer.

In 83 cases, the surgery was completed before the error was detected, the report by the Pennsylvania Safety Authority found.

The report, which covered the 36-month period that ended December 31, 2006, also said a third of the hospitals in Pennsylvania reported a wrong-site surgery or near-miss, the Inquirer reported.

In one instance, physicians removed a patient's healthy thyroid after a laboratory error led to an incorrect cancer diagnosis, the paper said. In another case, a doctor halted a procedure after making an incision on the wrong side of the patient's head.

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