LAUSR

n 1980, McLain identified the top five risk management issues in the OR as wrong patient; wrong procedure performed; improper consent; unreconciled sponge, needle, or instrument count; and burns from equipment. Approximately 20 years later, the Institute of Medicine report To Err Is Human: Building a Safer Health System described the complexity of health care systems in the United States and the epidemic occurrence of medical errors. Despite widespread awareness of medical errors, there has been little progress in this area to improve patient safety, and sentinel or never events continue to occur in the United States.