Wrong site surgery.

S. G. Fraser; W. Adams

Commentary

Wrong site surgery.

August 9, 2006

Fraser SG, Adams W. Br J Ophthalmol. 2006;90(7):814-6.

View more articles from the same authors.

The authors provide an overview of wrong site surgery, with special attention to incidents in ophthalmology.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

An observational study of laterality errors in a sample of clinical records.

April 9, 2008

Often overlooked problems with handoffs: from the intensive care unit to the operating room.

May 14, 2014

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

January 11, 2012

Diagnostic errors and diagnostic calibration.

September 6, 2017

The morbidity and mortality meeting: time for a different approach?

December 2, 2015

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Patients' and physicians' attitudes regarding the disclosure of medical errors.

March 6, 2005

Standard practices for computerized clinical decision support in community hospitals: a national survey.

July 11, 2012

From guideline to order set to patient harm.

April 4, 2018

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

March 13, 2013

The value from investments in health information technology at the U.S. Department of Veterans Affairs.

May 5, 2010

The investigation and analysis of critical incidents and adverse events in healthcare.

May 25, 2005

Medication assessments by care managers reveal potential safety issues in homebound older adults.

May 18, 2011

Health apps and health policy: what is needed?

October 24, 2018

From heroism to safe design: leveraging technology.

February 12, 2014

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

October 12, 2005

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.

December 2, 2020

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions.

March 7, 2018

Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit.

June 8, 2005

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.

July 10, 2013

Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study.

May 17, 2017

Using prospective clinical surveillance to identify adverse events in hospital.

March 30, 2011

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

Countering cognitive biases in minimising low value care.

June 7, 2017

Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics.

July 25, 2012

Risk management: extreme honesty may be the best policy.

March 27, 2005

Tracing the foundations of a conceptual framework for a patient safety ontology.

September 22, 2010

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

To expand the evidence base about harms from tests and treatments.

September 15, 2021

Measuring hospital-acquired complications associated with low-value care.

March 6, 2019

Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare beneficiaries.

August 11, 2021

Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention.

April 12, 2017

Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices.

August 26, 2009

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

August 16, 2017

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Antibiotic shortages in pediatrics.

November 14, 2018

Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.

November 9, 2005

Ambulatory virtual care during a pandemic: patient safety considerations.

March 9, 2022

Communication in healthcare: a narrative review of the literature and practical recommendations.

July 29, 2015

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

March 22, 2017

Effectiveness of surgical safety checklists in improving patient safety.

April 27, 2016

What did the doctor say? Health literacy and recall of medical instructions.

May 16, 2012

Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?

January 7, 2009

Learning from errors: analysis of medication order voiding in CPOE systems.

March 15, 2017

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

October 13, 2021

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

June 14, 2006

EMS helicopter crashes: what influences fatal outcome?

April 19, 2006

January 19, 2011

Medical error disclosure among pediatricians: choosing carefully what we might say to parents.

October 15, 2008

Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.

April 15, 2020

Essential activities for electronic health record safety: a qualitative study.

March 20, 2019

Antibiotic prescribing in ambulatory pediatrics in the United States.

January 11, 2012

Increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients.

April 13, 2011

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

October 19, 2016

Reduced effectiveness of interruptive drug–drug interaction alerts after conversion to a commercial electronic health record.

May 30, 2018

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

July 1, 2015

Computerised prescribing for safer medication ordering: still a work in progress.

November 18, 2015

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.

May 30, 2018

Avoiding the unintended consequences of growth in medical care: how might more be worse?

March 6, 2005

Do physicians clean their hands? Insights from a covert observational study.

July 27, 2016

A framework for encouraging patient engagement in medical decision making.

August 29, 2012

Using nurses and office staff to report prescribing errors in primary care.

May 7, 2008

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

July 18, 2007

Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.

January 16, 2019

Patient concerns about medical errors in emergency departments.

March 6, 2005

Communication factors in the follow-up of abnormal mammograms.

March 6, 2005

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the Prevention Epicenter Program.

January 18, 2006

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

May 24, 2017

Medication errors in anaesthesia and critical care.

April 3, 2005

Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems.

April 8, 2015

How house officers cope with their mistakes.

March 6, 2005

Do house officers learn from their mistakes?

March 6, 2005

Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study.

May 4, 2005

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.

July 18, 2012

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

March 2, 2016

Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?

April 24, 2019

Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system.

October 17, 2018

Improving safety through speaking up: an ethical and financial imperative.

July 24, 2019

Risk managers, physicians, and disclosure of harmful medical errors.

February 24, 2010

Addressing the elephant in the room: a shame resilience seminar for medical students.

August 28, 2019

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.

May 1, 2019

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

August 24, 2011

The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives.

February 7, 2007

Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.

May 19, 2021

Psychological responses, coping and supporting needs of healthcare professionals as second victims.

November 2, 2016

Incidence and preventability of adverse drug events in hospitalized patients.

March 6, 2005

Interventions to increase clinical incident reporting in health care.

September 5, 2012

Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.

July 13, 2005

Patient-specific electronic decision support reduces prescription of excessive doses.

May 26, 2010

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

June 14, 2006

Organizational culture and its implications for infection prevention and control in healthcare institutions.

January 8, 2014

Improving end of life care: an information systems approach to reducing medical errors.

June 15, 2005

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

February 23, 2011

Current challenges in health information technology–related patient safety.

January 16, 2019

Communication failures in the operating room: an observational classification of recurrent types and effects.

March 6, 2005

Safe prescribing: an educational intervention for medical students.

July 19, 2006

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

May 24, 2006

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.

April 30, 2008

Related Resources

Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

October 18, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

WebM&M Cases

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

October 27, 2021

Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.

August 11, 2021

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

April 1, 2020

Surgical data recording technology: a solution to address medical errors?

September 18, 2019

Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.

September 18, 2019

Patient safety incidents caused by poor quality surgical instruments.

September 4, 2019

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.

May 2, 2018

Preoperative site marking: are we adhering to good surgical practice?

July 26, 2017

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

Guideline implementation: prevention of retained surgical items.

August 3, 2016

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

June 15, 2016

Improving Weekend Out Of Hours Surgical Handover (WOOSH).

May 25, 2016

Back to basics: counting soft surgical goods.

April 20, 2016

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data.

September 24, 2014

The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.

September 10, 2014

Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.

July 30, 2014

Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.

July 23, 2014

Wrong-side thoracentesis: lessons learned from root cause analysis.

July 2, 2014

"It is the left eye, right?"

June 11, 2014

The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.

May 7, 2014

The quest for safe surgical care: are we missing the obvious?

April 23, 2014

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

March 26, 2014

Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis.

November 6, 2013

Using "near misses" analysis to prevent wrong-site surgery.

October 30, 2013

See More About The Topic

Quality and Safety Professionals

Wrong site surgery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Wrong site surgery.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site