AHRQ Patient Safety Network

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Approach to Improving Safety
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Read Back Protocols

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•Health Care Providers (50)

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•Hospitals (51)

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COMMENTARY

Getting to the Root of the Matter

Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

CLINICAL GUIDELINE

Prevention of wrong-site tooth extraction: clinical guidelines.

Lee JS, Curley AW, Smith RA. J Oral Maxillofac Surg. 2007;65:1793-1799.

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.

COMMENTARY

Triple Handoff

Vidyarthi AR. AHRQ WebM&M [serial online]. September 2006.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

COMMENTARY

The 2-Week Itch.

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

COMMENTARY

Surgical site verification: A through Z.

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

COMMENTARY

40 of K.

Lesar TS. AHRQ WebM&M [serial online]. November 2003.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 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.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:811, 815, 902.

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

Mark My Tooth

Smith RA. AHRQ WebM&M [serial online]. July 2007.

STUDY

Opportunities for performance improvement in relation to medication administration during pediatric stabilization.

Morgan N, Luo X, Fortner C, Frush K. Qual Saf Health Care. 2006;15:179-183.

COMMENTARY

Critical laboratory value notification: a failure mode effects and criticality analysis.

Saxena S, Kempf R, Wilcox S, et al. Jt Comm J Qual Patient Saf. 2005;31:495-506.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

STUDY

Expanded surgical time out: a key to real-time data collection and quality improvement.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. J Am Coll Surg. 2007;204:527-532.

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