PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
North America (45)
Journal Article (39)
Newspaper/Magazine Article (9)
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Epidemiology of Errors and Adverse Events (20)
Active Errors (32)
Latent Errors (8)
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Approach to Improving Safety
Quality Improvement Strategies (14)
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Error Reporting and Analysis (16)
Communication Improvement (21)
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Culture of Safety (3)
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Health Care Providers (38)
Health Care Executives and Administrators (43)
Non-Health Care Professionals (20)
Setting of Care
Ambulatory Care (5)
Outpatient Surgery (2)
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Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.
ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.
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.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.
Smith AF, Casey K, Wilson J, Fischbacher-Smith D. Int J Qual Health Care. 2011;23:590-599.
Specimen labeling errors in surgical pathology: an 18-month experience.
Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.
Preventing wrong site, procedure, and patient events using a common cause analysis.
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.
Variation in surgical time-out and site marking within pediatric otolaryngology.
Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.
Doctor removes ovaries from wrong patient.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Mix-up: baby nursed by wrong mother.
Cisneros N. ABC-7/KGO-TV. June 10, 2006.
Minnesota Time Out Campaign.
Minnesota Safe Surgery Coalition. June 15, 2011.
Hall LW. AHRQ WebM&M [serial online]. October 2008.
'Wrong-site' surgical mistakes are rare, preventable.
Stein L. St. Petersburg Times. June 21, 2010.
EMR Entry Error: Not So Benign
Koppel R. AHRQ WebM&M [serial online]. April 2009.
A case of mistaken identity: staff input on patient ID errors.
Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Minimizing electronic health record patient–note mismatches.
Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.
Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.
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