U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
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Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Butcher L. Hosp Health Netw. November 2011.
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.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
The Other Side.
Vincent C. AHRQ WebM&M [serial online]. October 2003.
Application of human error theory in case analysis of wrong procedures.
Duthie EA. J Patient Saf. 2010;6:108-114.
Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
When it's surgery, don't get it wrong.
Grant T. Washington Post. July 22, 2008:HE01
The pain of wrong site surgery.
Boodman SG. Washington Post. June 21, 2011:E1.
Incidence, patterns, and prevention of wrong-site surgery.
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.
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