AHRQ Patient Safety Network

The Collection > Wrong Patient

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

Narrow By

clear selections

Safety Target
< All

Wrong Patient

Origin/Sponsor

Resource Types

•Journal Article (37)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (9)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (30)

•Latent Errors (8)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (13)

•Legal and Policy Approaches (4)

•Error Reporting and Analysis (14)

•Communication Improvement (22)

•Human Factors Engineering (11)

•Teamwork (5)

•Logistical Approaches (3)

•Culture of Safety (3)

•Technologic Approaches (17)

•Education and Training (9)

Clinical Areas

•Medicine (41)

•Nursing (5)

•Pharmacy (1)

Target Audience

•Health Care Providers (36)

•Health Care Executives and Administrators (40)

•Non-Health Care Professionals (18)

•Patients (12)

Setting of Care

•Hospitals (39)

•Ambulatory Care (5)

•Outpatient Surgery (2)

1 - 20 of 54

Show ExcerptDon't Show Excerpt

dropdown

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

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.

MULTI-USE WEBSITE

National Time Out Day.

AORN Patient Safety First. June 12, 2013.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Doing the "right" things to correct wrong-site surgery.

PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.

NEWSPAPER/MAGAZINE ARTICLE

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

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

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.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

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

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.

STUDY

Patient misidentification in the neonatal intensive care unit: quantification of risk.

Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.

NEWSPAPER/MAGAZINE ARTICLE

How to avoid falling victim to a hospital mistake.

Cohen E. Empowered Patient. CNN.com. November 13, 2009.

STUDY

Application of human error theory in case analysis of wrong procedures.

Duthie EA. J Patient Saf. 2010;6:108-114.

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.

FACT SHEET/FAQS

Speak Up: Help Avoid Mistakes in Your Surgery.

Oakbrook Terrace, IL: Joint Commission.

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

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.

AUDIOVISUAL PRESENTATION

Mix-up: baby nursed by wrong mother.

Cisneros N. ABC-7/KGO-TV. June 10, 2006.

1 2 3 Next >