8 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 8
Editor's Page
Dan O'Connor
T
his issue fea-
tures back-to-
back articles on
never events —
retained objects and
wrong-site surgery.
It's refreshing that
both are first-person
accounts bravely told
by a nurse and a sur-
geon you'd certainly excuse if they passed on the chance to talk about
how they messed up.
But in swallowing their foolish pride and mustering the courage to
show they're fallible, they rose above medicine's blame-and-shame
culture that makes it nearly impossible to admit mistakes — not I
made a mistake, but I am a mistake — let alone learn from them and
prevent them happening again to another patient and provider.
• In "Almost Left Behind" on p. 18, Jean Campbell, MSN, RN, the
assistant manager and clinical educator of surgical services at Alton
(Ill.) Memorial Hospital, takes us along on her investigation into how
an OR team closed a patient with 2 sponges inside her. Though tech-
nically a near miss because the patient was still in the OR when they
realized the error, they had to put the patient back under and reopen
to get the sponges out.
• In "The Ink Must Go Where the Knife Will Cut" on p. 22, hand and
arm surgeon David Ring, MD, PhD, tells for the umpteenth time how
he performed the wrong hand surgery procedure. Dr. Ring says he felt
We All Make Mistakes, But Few Talk About Them
Two brave authors in this issue open up about their never events.