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Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
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Inadvertent Castration.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
STUDY
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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Resource Type
Commentary
Setting of Care
Operating Room
Target Audience
Health Care Providers
Clinical Area
Surgery
Nursing
Safety Target
Identification Errors
Preoperative Complications
Wrong-Site Surgery
Wrong-Site Surgery
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Near Miss
Approach to Improving Safety
Critical Pathways
Read Back Protocols
Checklists
Teamwork Training
Culture of Safety
Teamwork Training
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)