AHRQ Patient Safety Network

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Wrong-Site Surgery

Origin/Sponsor

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (50)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (23)

•Tools/Toolkit (2)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (42)

•Latent Errors (4)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (29)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (34)

•Communication Improvement (47)

•Human Factors Engineering (24)

•Teamwork (13)

•Specialization of Care (1)

•Logistical Approaches (2)

•Culture of Safety (8)

•Technologic Approaches (3)

•Education and Training (14)

Clinical Areas

•Dentistry (1)

•Medicine (78)

•Nursing (4)

Target Audience

•Health Care Providers (62)

•Health Care Executives and Administrators (59)

•Non-Health Care Professionals (12)

•Patients (25)

Setting of Care

•Hospitals (73)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (6)

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COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

AUDIOVISUAL

Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.

NEWSPAPER/MAGAZINE ARTICLE

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

Young A. The Atlanta Journal-Constitution. May 3, 2009:B1.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

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

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY

Time out: an analysis.

Dillon KA. AORN J. 2008;88:437-442.

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

REVIEW

Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.

Dagi TF, Berguer R, Moore S, Reines HD. Curr Probl Surg. 2007;44:352-381.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

STUDY

Getting surgery right.

Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

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