U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
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Surgical Complications (638)
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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.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
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.
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.
Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
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.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Butcher L. Hosp Health Netw. November 2011.
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.
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.
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.
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.
Doctor uses 'pre-flight' checklist.
Bernhard B. The Orange County Register. April 19, 2006.
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.
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