Journal Article
Study

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

Paull DE; Mazzia LM; Neily J; Mills PD; Turner JR; Gunnar W; Hemphill R.

This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery events can occur despite adherence to the Universal Protocol, due to errors preceding and following the protocol's use. The authors suggest that additional processes initialized earlier and continuing later through the surgical process are required to fully prevent these events.