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 (68)

Resource Types

•Book/Report (4)

•Clinical Guideline (1)

•Journal Article (43)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (21)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (22)

•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 (26)

•Communication Improvement (42)

•Human Factors Engineering (21)

•Teamwork (14)

•Specialization of Care (1)

•Logistical Approaches (2)

•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 (50)

•Non-Health Care Professionals (13)

•Patients (23)

Setting of Care

•Hospitals (66)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (4)

•Outpatient Surgery (6)

1 - 20 of 78

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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

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.

STUDY

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

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

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

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

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

Eight-year experience with a neurosurgical checklist.

Lyons MK. Am J Med Qual. 2010;25:285-288.

STUDY

Wrong site surgery near misses and actual occurrences.

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

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

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

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

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.

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.

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

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

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.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

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