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?