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- Cognitive Errors ("Mistakes")
- Orthopedic Surgery
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.
Journal Article > Study
The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.
James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. J Bone Joint Surg Am. 2012;94:e2(1-12).