Wrong site surgery & surgical time out
“In 1935, the US Army Air Corps held a flight competition for airplane manufacturers vying to build its next generation long range bomber. In early evaluations, the Boeing plane had surpassed designs. The flight competition, was regarded as a mere formality. With the most technically gifted test pilot in the army on board, the plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot. An investigation revealed that nothing mechanical had gone wrong. The pilot had forgotten to release the new locking mechanism on the elevator and rudder controls. A few months later army pilots were convinced the plane could fly and invented something that would be used on the few planes that had been purchased….A checklist, with step by step checks for takeoff, flight, landing and taxiing. With the checklist in hand the pilots went on to fly the model (B-17) a total of 1.8 million miles through several conflicts without one accident”. (Gawande A. 2007) This episode has been heralded as the key milestone in the birth of the checklist.