U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Australia and New Zealand (3)
North America (80)
Clinical Guideline (1)
Journal Article (59)
Newspaper/Magazine Article (22)
Web Resource (3)
Epidemiology of Errors and Adverse Events (32)
Active Errors (44)
Latent Errors (5)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (31)
Legal and Policy Approaches (14)
Error Reporting and Analysis (38)
Communication Improvement (45)
Human Factors Engineering (25)
Specialization of Care (1)
Logistical Approaches (3)
Culture of Safety (10)
Technologic Approaches (5)
Education and Training (16)
Health Care Providers (65)
Health Care Executives and Administrators (68)
Non-Health Care Professionals (18)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (8)
1 - 20
Don't Show Excerpt
Sort by significance
Sort by title
Sort by date
Sort by author
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Gallagher TH. JAMA. 2009;302:669-677.
Joint Commission Center for Transforming Healthcare.
The Joint Commission.
Incidence, patterns, and prevention of wrong-site surgery.
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
Wrong-side thoracentesis: lessons learned from root cause analysis.
Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014 Jun 11; [Epub ahead of print].
Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
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.
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.
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.
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.
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.
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Washington Patient Safety Coalition.
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
Improving America's Hospitals: A Report on Quality and Safety.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Terms & Conditions
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.