When There Is A Sentinel Event, Generally There Were Systemic Issues Or Three Breakdowns Minimum That Resulted In The Error. How Many Times Do You Think A Time-Out Is Called With Safety Checks, Wrist Band Identifiers And Other Cross Checks Gone Through

When there is a sentinel event, generally there were systemic issues or three breakdowns minimum that resulted in the error. How many times do you think a time-out is called with safety checks, wrist band identifiers and other cross checks gone through accurately. Many times the wrong band is on the wrong patient.
Thoughts?