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Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts.

This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.

The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list. 

This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.

This notice highlights the importance of standardizing wristband design and information to make their use consistent for every patient in the United Kingdom.

This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.

This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.

This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.

This report discusses the impact that automated technologies, such as radio frequency identification (RFID) and barcoding, could have on health care in the United Kingdom and provides a plan to support their adoption in the National Health Service.

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.

This supplemental advisory recommends that a limited, standard set of colors and corresponding terms accompany wristband use.

This Web site provide resources for improving patient safety in the National Health Service, including a place for practitioners to ask questions and share experiences with one another.

Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.