The High Cost of Low-Frequency Events

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Abstract
We conducted a one-year prospective survey to identify adverse outcomes due to error during care in the field of general surgery. We identified 36 such cases among 5612 surgical admissions to the Peter Bent Brigham Hospital, but in 23 cases the initiating mishap had occurred in another hospital before transfer. In two thirds of the cases the mishap was due to an error of commission: an unnecessary, defective, or inappropriate operative procedure.

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