U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Wrong Patient (25)
Wrong-Site Surgery (73)
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Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Doctor uses 'pre-flight' checklist.
Bernhard B. The Orange County Register. April 19, 2006.
Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
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.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
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.
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.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
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.
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.
Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.
Knight N, Aucar J. Am J Surg. 2010;200:803-807.
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.
Meeting the Joint Commission's 2013 National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Application of human error theory in case analysis of wrong procedures.
Duthie EA. J Patient Saf. 2010;6:108-114.
'Wrong-site' surgical mistakes are rare, preventable.
Stein L. St. Petersburg Times. June 21, 2010.
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.
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