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Objective: To investigate the hypothesis that surgical confusions rarely occur but are unacceptable to the public; occur in predictable circumstances; involve a wrong lens implant more often than a wrong eye, procedure, or patient; and can be prevented using the Universal Protocol. Methods: A retrospective series of 106 cases, including 42 from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department. We investigated how the error occurred; when and by whom itdoi:10.1001/archopht.125.11.1515 pmid:17998513 fatcat:2bfkqyur7ncfnh3iscj5r5l23q