AHRQ Patient Safety Network

Right? Left? Neither! AHRQ WebM&M icon

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.

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Resource Type

Commentary

Setting of Care

Emergency Departments

Operating Room

Ambulatory Clinic or Office

Target Audience

Physicians

Nurses

Risk Managers

Quality and Safety Professionals

Organizational Behaviorists

Clinical Area

Anesthesiology

Radiology

Surgery

Safety Target

Discontinuities, Gaps, and Hand-Off Problems

Wrong Patient

Wrong-Site Surgery

Error Types

Noncognitive Errors ("Slips & Lapses")

Latent Errors

Approach to Improving Safety

Quality Improvement Strategies

Communication between Providers

Provider-Patient Communication

Teamwork

Computerized Decision Support