U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
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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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.
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.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
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.
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.
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.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
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.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
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.
Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography.
Tridandapani S, Ramamurthy S, Galgano SJ, Provenzale JM. AJR Am J Roentgenol. 2013;200:W345-W352.
Matching identifiers in electronic health records: implications for duplicate records and patient safety.
McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.
Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.
Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.
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