the preoperative briefing led the team to recognize that a vial of potassium chloride had been switched with an antibiotic vial—a potentially lethal mix-up. In another, the checklist led the staff to catch a paperwork error that had them planning for a thoracotomy, an open-chest procedure with a huge front-to-back wound, when what the patient had come in for was actually a thoracoscopy, a videoscope procedure done through a quarter-inch incision.
