AHRQ Patient Safety Network

The Collection > Wrong-Site Surgery

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

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Wrong-Site Surgery

Origin/Sponsor

•Australia and New Zealand (1)

•Europe (6)

•North America (67)

Resource Types

•Book/Report (4)

•Clinical Guideline (1)

•Journal Article (42)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (21)

•Tools/Toolkit (3)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (23)

•Active Errors (35)

•Latent Errors (2)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (27)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (24)

•Communication Improvement (42)

•Human Factors Engineering (21)

•Teamwork (13)

•Logistical Approaches (3)

•Culture of Safety (11)

•Technologic Approaches (3)

•Education and Training (14)

Clinical Areas

•Dentistry (1)

•Medicine (67)

•Nursing (3)

Target Audience

•Health Care Providers (51)

•Health Care Executives and Administrators (49)

•Non-Health Care Professionals (12)

•Patients (24)

Setting of Care

•Hospitals (65)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (4)

•Outpatient Surgery (6)

1 - 20 of 77

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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

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.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Which End is Which?

Campbell AR. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

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.

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.

STUDY

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

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

COMMENTARY

The Other Side.

Vincent C. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

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

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

Smith S. Boston Globe. July 4, 2008;Metro section:1A.

STUDY

Wrong site surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

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