U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
2014 ANNUAL PERSPECTIVES
North America (42)
Journal Article (41)
Newspaper/Magazine Article (9)
Epidemiology of Errors and Adverse Events (21)
Active Errors (33)
Latent Errors (7)
Near Miss (2)
Approach to Improving Safety
Quality Improvement Strategies (14)
Legal and Policy Approaches (3)
Error Reporting and Analysis (16)
Communication Improvement (19)
Human Factors Engineering (13)
Logistical Approaches (2)
Culture of Safety (3)
Technologic Approaches (20)
Education and Training (6)
Health Care Providers (36)
Health Care Executives and Administrators (44)
Non-Health Care Professionals (19)
Setting of Care
Ambulatory Care (6)
Outpatient Surgery (2)
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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.
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.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
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.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
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.
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.
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
The wrong patient.
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
Specimen labeling errors in surgical pathology: an 18-month experience.
Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.
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.
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.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
Patients put at risk by NHS computer fault.
Gray R. Scotland on Sunday. January 8, 2006.
To Resuscitate or Not?
Wu AW, Pronovost PJ. AHRQ WebM&M [serial online]. January 2004.
An observational study of how patients are identified before medication administrations in medical and surgical wards.
Härkänen M, Kervinen M, Ahonen J, Turunen H, Vehviläinen-Julkunen K. Nurs Health Sci. 2014 Jul 8; [Epub ahead of print].
Patient identification errors: the detective in the laboratory.
Salinas M, López-Garrigós M, Lillo R, Gutiérreza M, Lugo J, Leiva-Salinas C. Clin Biochem. 2013;46:1767-1769.
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