AHRQ Patient Safety Network

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Approach to Improving Safety
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Read Back Protocols

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Target Audience

•Health Care Providers (79)

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•Hospitals (89)

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COMMENTARY

Surgical site verification: A through Z.

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

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

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

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

NEWSPAPER/MAGAZINE ARTICLE

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

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

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.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

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.

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

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

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

NEWSPAPER/MAGAZINE ARTICLE

Preventing surgical errors.

Frenzel JC, Kelly T. HHN Magazine Online. January 6, 2009.

COMMENTARY

Time out: an analysis.

Dillon KA. AORN J. 2008;88:437-442.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-patient, wrong-site procedures persist despite safety protocol.

O'Reilly KB. American Medical News; Nov. 1, 2010.

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.

NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

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