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 (66)

Resource Types

•Book/Report (4)

•Clinical Guideline (1)

•Journal Article (42)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (21)

•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 (24)

•Communication Improvement (42)

•Human Factors Engineering (21)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (3)

•Culture of Safety (11)

•Technologic Approaches (3)

•Education and Training (13)

Clinical Areas

•Dentistry (1)

•Medicine (67)

•Nursing (3)

Target Audience

•Health Care Providers (51)

•Health Care Executives and Administrators (49)

•Non-Health Care Professionals (11)

•Patients (23)

Setting of Care

•Hospitals (65)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (4)

•Outpatient Surgery (6)

1 - 20 of 76

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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.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 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

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.

STUDY

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

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

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 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

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

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.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

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

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

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

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.

COMMENTARY

What Can the Rest of the Health Care System Learn from the VA’s Quality and Safety Transformation?

Jha AK. AHRQ WebM&M [serial online]. September 2006.

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

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

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

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

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

COMMENTARY

Mark My Limb.

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

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