Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures—perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them. But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally
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