U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
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Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
Surgical specimen identification errors: a new measure of quality in surgical care.
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.
Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.
Tomorrow's operating room to harness Net, RFID.
Olsen S. CNET News.com; October 19, 2005.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
Butcher L. Hosp Health Netw. November 2011.
Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.
Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.
Video technology to advance safety in the operating room and perioperative environment.
Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.
Surgical team behaviors and patient outcomes.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
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