U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Wrong Patient (27)
Wrong-Site Surgery (76)
Australia and New Zealand (1)
North America (151)
Clinical Guideline (1)
Journal Article (102)
Newspaper/Magazine Article (40)
Special or Theme Issue (2)
Web Resource (5)
Epidemiology of Errors and Adverse Events (45)
Active Errors (71)
Latent Errors (13)
Near Miss (11)
Approach to Improving Safety
Quality Improvement Strategies (57)
Legal and Policy Approaches (17)
Error Reporting and Analysis (55)
Communication Improvement (72)
Human Factors Engineering (46)
Specialization of Care (2)
Logistical Approaches (21)
Culture of Safety (16)
Technologic Approaches (30)
Education and Training (29)
Health Care Providers (114)
Health Care Executives and Administrators (128)
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.
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.
Getting surgery right.
Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.
Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
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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