You are the risk manager of a hospital. A nurse from the operating room reports that, during a surgery, the head surgeon did not conduct a “time out” to confirm the side and site of the surgery. You question the surgeon, and he denies the incident. There is no injury to the patient.
What is the nature of the risk? Who is at risk? What additional information do you require? What actions can be taken to prevent recurrence of the incident?

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