On at least three occasions in 2007, surgeons at one Rhode Island hospital operated on the wrong side of their patients' heads. In one case, a resident neurosurgeon inserted a scalpel into the head of an 82-year-old patient. The surgeon noticed the error before reaching the skull and stitched up the wound, but the state health department fined the hospital $50,000.
This sort of error is not terrifically rare. Based on malpractice judgments and out-of-court settlements for things like operating on the wrong side of a patient, or on the wrong patient, or leaving a sponge or other surgical object inside of a patient, researchers at Johns Hopkins estimate that such errors—called "never events" by hospital risk managers—occur not never, but more than 4,000 times in the U.S. every year.
In recent years, the vogue solution in preventing this sort of error has been a seemingly simple one: using checklists. The idea is that using checklists could prevent this sort of surgical error, and their associated (often massive) costs.
The idea became widely popular in 2009, after surgeon and Harvard professor Atul Gawande published a book called The Checklist Manifesto that, true to its title, implored doctors to use even basic checklists to avoid egregious errors of omission. And, ideally, all errors. It was based on research he published in the New England Journal of Medicine in January of the same year, which found that implementing a system of checklists to ensure basic safety standards is extremely effective. In fact, use of a straightforward 19-point checklist was able to decrease the rate of death in or after surgery by almost half.