of the patient’s identity and procedure, the appropriate placement of intravenous lines for patients who develop severe bleeding, and finally a complete accounting of sponges at the end of the procedure. These are basics, the surgical equivalent of unlocking the elevator controls before airplane takeoff. Nevertheless, we found gaps everywhere. The very best missed at least one of these minimum steps 6 percent of the time—once in every sixteen patients. And on average, the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed
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