A Double “Never Event”: Wrong Patient and Wrong Side. Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS | September 27, 2023

A Double “Never Event”: Wrong Patient and Wrong Side. Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS | September 27, 2023 https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side This WebM&M Case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.