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Wrong-Site Surgery
PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
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Wrong-Site Surgery
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STUDY
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
STUDY
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
COMMENTARY
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Gallagher TH. JAMA. 2009;302:669-677.
STUDY
Incidence, patterns, and prevention of wrong-site surgery.
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
MULTI-USE WEBSITE
Joint Commission Center for Transforming Healthcare.
The Joint Commission.
BOOK/REPORT
Adverse Health Events in Minnesota: Ninth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2013.
STUDY
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.
STUDY
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.
STUDY
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.
ORGANIZATIONAL POLICY/GUIDELINES
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
STUDY
Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.
Frey B, Ersch J, Bernet V, Baenziger O, Enderli L, Doell C. Qual Saf Health Care. 2009;18:446-449.
STUDY
Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
STUDY
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.
STUDY
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
STUDY
Hospitalized patients' attitudes about and participation in error prevention.
Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. J Gen Intern Med. 2006;21:367-370.
MULTI-USE WEBSITE
National Time Out Day.
AORN Patient Safety First.
MULTI-USE WEBSITE
Minnesota Time Out Campaign.
Minnesota Safe Surgery Coalition. June 15, 2011.
STUDY
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.
NEWSPAPER/MAGAZINE ARTICLE
The pain of wrong site surgery.
Boodman SG. Washington Post. June 21, 2011:E1.
STUDY
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.
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