AHRQ Patient Safety Network

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Wrong-Site Surgery

Origin/Sponsor

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (51)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (23)

•Tools/Toolkit (2)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (28)

•Active Errors (42)

•Latent Errors (3)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (30)

•Legal and Policy Approaches (14)

•Error Reporting and Analysis (34)

•Communication Improvement (45)

•Human Factors Engineering (25)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (2)

•Culture of Safety (10)

•Technologic Approaches (4)

•Education and Training (15)

Clinical Areas

•Dentistry (1)

•Medicine (78)

•Nursing (4)

Target Audience

•Health Care Providers (62)

•Health Care Executives and Administrators (61)

•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 87

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NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

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

COMMENTARY

Surgical site verification: A through Z.

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

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

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.

NEWSPAPER/MAGAZINE ARTICLE

How to avoid falling victim to a hospital mistake.

Cohen E. Empowered Patient. CNN.com. November 13, 2009.

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

Medical culture about errors may be changing.

Gulliver D. Herald Tribune. September 3, 2007.

MEASUREMENT TOOL/INDICATOR

AORN Evaluation of the Universal Protocol.

Association of PeriOperative Registered Nurses.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Another wrong-site surgery at RI Hospital.

Freyer FJ. Providence Journal. October 24, 2009.

COMMENTARY classic

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

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

Associated Press. MSNBC. November 27, 2007.

STUDY

Operating room briefings and wrong-site surgery.

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

FACT SHEET/FAQS

What is Correct-Site Surgery?

American College of Surgeons.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

STUDY

Wrong-site sinus surgery in otolaryngology.

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

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

Altman LK. New York Times. December 11, 2001;1:1.

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