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- Communication Improvement
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 1
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Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
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.
Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.
This newspaper article highlights a simple innovation one hospital is using to trigger a time out in the operating room.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.
Rojas-Burke J. The Oregonian. May 25, 2011.
Boodman SG. Washington Post. June 21, 2011:E1.
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.