AHRQ Patient Safety Network

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Wrong-Site Surgery

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (2)

•Europe (1)

•North America (61)

Resource Types

•Book/Report (4)

•Journal Article (43)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (18)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (37)

•Latent Errors (3)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (22)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (28)

•Communication Improvement (37)

•Human Factors Engineering (20)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (2)

•Culture of Safety (10)

•Technologic Approaches (5)

•Education and Training (13)

Clinical Areas

•Medicine (61)

•Nursing (4)

Target Audience

•Health Care Providers (51)

•Health Care Executives and Administrators (50)

•Non-Health Care Professionals (11)

•Patients (18)

Setting of Care

•Hospitals (56)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (5)

1 - 20 of 68

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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

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

Wrong-site sinus surgery in otolaryngology.

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

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

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

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

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

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

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

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

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

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.

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

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

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.

COMMENTARY

Mark My Limb.

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

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

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