AHRQ Patient Safety Network

The Collection > Wrong Patient

PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery

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Wrong Patient

Origin/Sponsor

Resource Types

•Journal Article (37)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (8)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (19)

•Active Errors (31)

•Latent Errors (7)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (12)

•Legal and Policy Approaches (3)

•Error Reporting and Analysis (15)

•Communication Improvement (20)

•Human Factors Engineering (12)

•Teamwork (5)

•Logistical Approaches (2)

•Culture of Safety (3)

•Technologic Approaches (18)

•Education and Training (6)

Clinical Areas

•Medicine (39)

•Nursing (2)

•Pharmacy (1)

Target Audience

•Health Care Providers (34)

•Health Care Executives and Administrators (40)

•Non-Health Care Professionals (18)

•Patients (11)

Setting of Care

•Hospitals (36)

•Ambulatory Care (5)

•Outpatient Surgery (2)

1 - 20 of 49

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STUDY

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.

STUDY

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.

STUDY

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.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

STUDY

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.

COMMENTARY

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.

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

COMMENTARY classic

The wrong patient.

Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

STUDY

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

STUDY

Specimen labeling errors in surgical pathology: an 18-month experience.

Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-patient, wrong-site procedures persist despite safety protocol.

O'Reilly KB. American Medical News; Nov. 1, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Patients put at risk by NHS computer fault.

Gray R. Scotland on Sunday. January 8, 2006.

STUDY

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.

COMMENTARY

To Resuscitate or Not?

Wu AW, Pronovost PJ. AHRQ WebM&M [serial online]. January 2004.

REVIEW

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Lippi G, Blanckaert N, Bonini P, et al. Clin Chem Lab Med. 2009;47:143-153.

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