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Boodman SG. Washington Post. June 21, 2011:E1.
This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.
Febrile Neutropenia and an Almost Fatal Medication Error
Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH
Adverse Health Events in Minnesota: 15th Annual Public Report.
St. Paul, MN: Minnesota Department of Health; March 2019.
A surgical procedure grid for safety and operating room communication in multisite surgery.
Insalaco LF, Spiegel JH. JAMA Facial Plast Surg. 2018;20:185-186.
Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318:2033-2034.
Joint Commission Center for Transforming Healthcare.
The Joint Commission.
Preventing wrong site, procedure, and patient events using a common cause analysis.
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
Outcome of 6 years of protocol use for preventing wrong site office surgery.
Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.
Wrong body part, wrong patient surgeries continue despite new procedures.
Rojas-Burke J. The Oregonian. May 25, 2011.
Process changes to increase compliance with the Universal Protocol for bedside procedures.
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.
Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.
Safe Site Invasive Procedure—Non-Operating Room.
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
Wrong-site sinus surgery in otolaryngology.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
How to avoid falling victim to a hospital mistake.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
Surgical site signing and "time out": issues of compliance or complacence.
Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.
Wrong site surgery near misses and actual occurrences.
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Gallagher TH. JAMA. 2009;302:669-677.
PSNET: Patient Safety Network
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