I was perusing Great Z's blog when I found this story which reminded me of something similar that happened at the C of E which unfortunately didn't go as well for the patient.
A patient with a previous esophagectomy and pull-thru presented for a CABG. Unbeknownst to the cardiac surgeon who never asked (or probably even talked to the patient or read his chart beyond the cardiac cath report), the pull thru had for some reason been done anterior rather than posterior to the mediastinum.
When they sawed thru the sternum, they also sawed thru the piece of colon that was now acting as the esophagus. Oops. A general surgeon was called to fix things and I don't think the gentleman got his CABG that day.
The surgery resident who looked up at the lateral CXR up on the viewbox which showed something in the anterior mediastinum which didn't belong there, said, "I guess we should have looked at that first!"