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Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg. 2007;245(4):526-32.

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April 25, 2007
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245(4):526-32.
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Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety

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Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg. 2007;245(4):526-32.

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