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Journal Article > Review
Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.
The author reviews the epidemiology of surgical adverse events from major epidemiologic studies and discusses the need for a systems approach to preventing wrong-site surgery with particular emphasis on spinal surgery.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Freyer FJ. Providence Journal. September 20, 2008.
This story reports on an incident involving wrong-side surgery and describes how the hospital responded to the event.
Journal Article > Study
Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.
Adherence to measures to prevent wrong-site surgery remained lower than optimal over a 2-year period, in this study conducted at two teaching hospitals in Canada.
Journal Article > Study
Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-449.
Improving perioperative safety requires optimal communication within the surgical team; however, classic studies have shown that teamwork in the operating room is often suboptimal. This study successfully improved communication and safety through creation of a structured preoperative briefing protocol for gynecologic and orthopedic procedures. The protocol required discussion of critical operative elements between the surgeons, anesthesiologists, and nurses prior to surgery. Checklists have been remarkably successful at reducing perioperative adverse events, and this protocol incorporated some elements of previously published perioperative checklists and The Joint Commission's Universal Protocol. However, the protocol used in this study focused on creating shared situational awareness among all team members, and did not explicitly mandate specific steps as in a checklist. An accompanying editorial discusses the cultural challenges that have accompanied attempts to improve surgical safety.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.