AHRQ Patient Safety Network

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Read Back Protocols

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Target Audience

•Health Care Providers (83)

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•Hospitals (91)

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COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

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

A review of verbal order policies in acute care hospitals.

Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.

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.

COMMENTARY

Decreasing patient misidentification before chemotherapy administration.

Spruill A, Eron B, Coghill A, Talbert G. Clin J Oncol Nurs. 2009;13:716-717.

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.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: what can medicine learn from aviation?

O'Reilly KB. American Medical News. June 14, 2010.

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.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

COMMENTARY

Mistaken Identity

Hall LW. AHRQ WebM&M [serial online]. October 2008.

COMMENTARY classic

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

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

COMMENTARY

The 2-Week Itch.

Cohen MR. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

Check the Bags.

Caldwell M, Dracup KA. AHRQ WebM&M [serial online]. September 2003.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

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