U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Wrong Patient (25)
Wrong-Site Surgery (76)
Australia and New Zealand (1)
North America (149)
Clinical Guideline (1)
Journal Article (100)
Newspaper/Magazine Article (40)
Special or Theme Issue (2)
Web Resource (5)
Epidemiology of Errors and Adverse Events (45)
Active Errors (69)
Latent Errors (13)
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Approach to Improving Safety
Quality Improvement Strategies (57)
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Error Reporting and Analysis (54)
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Human Factors Engineering (46)
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Logistical Approaches (21)
Culture of Safety (16)
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Education and Training (29)
Health Care Providers (114)
Health Care Executives and Administrators (126)
Non-Health Care Professionals (38)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (2)
Ambulatory Care (11)
Outpatient Surgery (11)
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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.
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.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
'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.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
Doctor uses 'pre-flight' checklist.
Bernhard B. The Orange County Register. April 19, 2006.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Getting surgery right.
Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.
Applying fault tree analysis to the prevention of wrong-site surgery.
Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.
Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Safe Site Invasive Procedure—Non-Operating Room.
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
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