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-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.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
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.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
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.
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.
Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
To Resuscitate or Not?
Wu AW, Pronovost PJ. AHRQ WebM&M [serial online]. January 2004.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
Registration-associated patient misidentification in an academic medical center: causes and corrections.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
A case of mistaken identity: staff input on patient ID errors.
Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.
Patients put at risk by NHS computer fault.
Gray R. Scotland on Sunday. January 8, 2006.
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