AHRQ Patient Safety Network

The Collection > Wrong-Site Surgery

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Wrong-Site Surgery

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (52)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (23)

•Tools/Toolkit (2)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (41)

•Latent Errors (3)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (31)

•Legal and Policy Approaches (14)

•Error Reporting and Analysis (32)

•Communication Improvement (45)

•Human Factors Engineering (25)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (3)

•Culture of Safety (10)

•Technologic Approaches (5)

•Education and Training (15)

Clinical Areas

•Dentistry (1)

•Medicine (79)

•Nursing (5)

Target Audience

•Health Care Providers (62)

•Health Care Executives and Administrators (62)

•Non-Health Care Professionals (13)

•Patients (24)

Setting of Care

•Hospitals (74)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (6)

1 - 20 of 88

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NEWSPAPER/MAGAZINE ARTICLE

Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.

Smith S. Boston Globe. July 30, 2008;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

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

NEWSPAPER/MAGAZINE ARTICLE

Third wrong-sided brain surgery at R.I. hospital.

Associated Press. MSNBC. November 27, 2007.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

NEWSPAPER/MAGAZINE ARTICLE

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

Young A. The Atlanta Journal-Constitution. May 3, 2009:B1.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

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

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

FACT SHEET/FAQS

What is Correct-Site Surgery?

American College of Surgeons.

STUDY

Operating room briefings and wrong-site surgery.

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

STUDY

Getting surgery right.

Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.

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.

STUDY

Surgical site signing and "time out": issues of compliance or complacence.

Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.

NEWSPAPER/MAGAZINE ARTICLE

When it's surgery, don't get it wrong.

Grant T. Washington Post. July 22, 2008:HE01

STUDY

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. J Bone Joint Surg Am. 2012;94:e2(1-12).

NEWSPAPER/MAGAZINE ARTICLE

Medical culture about errors may be changing.

Gulliver D. Herald Tribune. September 3, 2007.

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