Even though simple checklists have been shown to improve outcomes over and over again, some doctors resist using them. Sometimes people count things incorrectly. It’s not that there continue to be fools, but that humans continue to be fallible. I’d suspect every one of us has, at some time, seriously fucked some thing up by being fallible in a stupid way.
The estimates range from .03-1% per 1,000 patients suffer through this. Given that there were about 15 million surgeries performed last year where this could occur, that number isn’t so surprising.
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