AHRQ Patient Safety Network

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•Device-related Complications (2)

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•Identification Errors (49)

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Approach to Improving Safety
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Read Back Protocols

Clinical Areas

Target Audience

•Health Care Providers (75)

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Setting of Care

•Hospitals (84)

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NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

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

Another wrong-site surgery at RI Hospital.

Freyer FJ. Providence Journal. October 24, 2009.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

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

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY classic

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

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

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

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.

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.

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

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

COMMENTARY

Surgical site verification: A through Z.

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

STUDY

Operating room briefings and wrong-site surgery.

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

STUDY

Getting surgery right.

Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

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

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.

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