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NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
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U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of Representatives, Subcommittee on Oversight and Investigations. 109 Congress, 2nd sess June 15, 2006. Washington, DC: US Government Printing Office; 2007.
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.
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JCAHO; Joint Commission on Accreditation of Healthcare Organizations.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
