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 (24)

•Tools/Toolkit (2)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (42)

•Latent Errors (4)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (31)

•Legal and Policy Approaches (14)

•Error Reporting and Analysis (35)

•Communication Improvement (48)

•Human Factors Engineering (25)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (3)

•Culture of Safety (10)

•Technologic Approaches (5)

•Education and Training (16)

Clinical Areas

•Dentistry (1)

•Medicine (81)

•Nursing (5)

Target Audience

•Health Care Providers (63)

•Health Care Executives and Administrators (63)

•Non-Health Care Professionals (13)

•Patients (25)

Setting of Care

•Hospitals (75)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (5)

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ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

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

REVIEW

Avoiding wrong site surgery: a systematic review.

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

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

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

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.

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

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 classic

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

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

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.

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.

STUDY

Eight-year experience with a neurosurgical checklist.

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

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

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

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

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.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Operating room briefings and wrong-site surgery.

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

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