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Changing our culture to advance patient safety

The 2013 AANS Presidential Address

Mitchel S. Berger, Robert M. Wachter, S. Ryan Greysen and Catherine Y. Lau

codes for these “never events,” recorded only 9 such events over a 3-year period. The ABNS Credentials Committee identified 41 wrong-site or wrong-side surgeries in a 10-year period. The Joint Commission reported nearly 900 wrong-patient/wrong-site/wrong-procedure events throughout surgery in general over an 8-year period. If we break out just neurosurgery, there were 27 “never events” in this 8-year period. So this averages out to be about 2–4 events per year. But there was an article that came out of a Canadian survey in which 25% of polled neurosurgeons reported