AHRQ Patient Safety Network

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•Device-related Complications (2)

•Diagnostic Errors (3)

•Identification Errors (49)

•Discontinuities, Gaps, and Hand-Off Problems (14)

•Medication Safety (14)

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•Nonsurgical Procedural Complications (2)

•Surgical Complications (75)

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•Epidemiology of Errors and Adverse Events (17)

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Approach to Improving Safety
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Read Back Protocols

Clinical Areas

Target Audience

•Health Care Providers (78)

•Health Care Executives and Administrators (75)

•Non-Health Care Professionals (11)

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Setting of Care

•Hospitals (87)

•Ambulatory Care (3)

•Outpatient Surgery (5)

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1 - 20 of 102

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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

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

STUDY

Operating room briefings and wrong-site surgery.

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

COMMENTARY

Surgical site verification: A through Z.

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

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 surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.

NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

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.

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.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

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

COMMENTARY classic

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

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

COMMENTARY

Time out: an analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

Another wrong-site surgery at RI Hospital.

Freyer FJ. Providence Journal. October 24, 2009.

MEASUREMENT TOOL/INDICATOR

AORN Evaluation of the Universal Protocol.

Association of PeriOperative Registered Nurses.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

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

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