-
1
-
-
0003413171
-
-
Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, DC: Institute of Medicine, National Academy Press
-
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy Press; 2000.
-
(2000)
To Err Is Human: Building a Safer Health System
-
-
-
2
-
-
33748805655
-
Wrong-sided anesthetic and surgical procedures: Are they preventable?
-
Paper presented: March 22,2003; New Orleans, La.
-
Seiden S, Kivlahan C, Runciman B, Christansen U, Barach P. Wrong-sided anesthetic and surgical procedures: are they preventable? Paper presented at: 77th Clinical & Scientific Congress, International Anesthesia Research Society; March 22,2003; New Orleans, La.
-
At: 77th Clinical & Scientific Congress, International Anesthesia Research Society
-
-
Seiden, S.1
Kivlahan, C.2
Runciman, B.3
Christansen, U.4
Barach, P.5
-
3
-
-
33748758850
-
Wrong-sided anesthetic and surgical procedures: Why do they continue to happen?
-
Paper presented: October 14, San Francisco, Calif.
-
Seiden S, Kivlahan C, Runciman B, Gosbee J, Barach P. Wrong-sided anesthetic and surgical procedures: why do they continue to happen? Paper presented at: Annual Meeting of the American Society of Anesthesiologists; October 14, 2003; San Francisco, Calif.
-
(2003)
Annual Meeting of the American Society of Anesthesiologists
-
-
Seiden, S.1
Kivlahan, C.2
Runciman, B.3
Gosbee, J.4
Barach, P.5
-
4
-
-
34447641831
-
Anesthesia and surgery: Not always a one-sided affair
-
Strelec SR. Anesthesia and surgery: not always a one-sided affair. ASA Newsletter. http://www.asahq.org/Newsletters/1996/06_96/feature4.htm. Accessed November 28, 2005.
-
ASA Newsletter
-
-
Strelec, S.R.1
-
6
-
-
0029385422
-
Problems in left-right discrimination in a high-IQ population
-
Storfer MD. Problems in left-right discrimination in a high-IQ population. Percept Mot Skills. 1995;81:491-497.
-
(1995)
Percept Mot Skills
, vol.81
, pp. 491-497
-
-
Storfer, M.D.1
-
8
-
-
33748792145
-
-
Title 410, Indiana Department of Public Health Indiana. LSA document #05-326 (E). January 1
-
Title 410, Indiana Department of Public Health Indiana. LSA document #05-326 (E). January 1, 2006. http://www.in.gov/isdh/news/pdfs/05-326(E) emergency_rule.pdf. Accessed June 14, 2006.
-
(2006)
-
-
-
9
-
-
33748795510
-
-
Minnesota Department of Health Web site. Updated March 16
-
Adverse health events reporting law: Minnesota's 27 reportable events. http://www.health.state.mn.us/patientsafety/adverse27events.html. Minnesota Department of Health Web site. Updated March 16, 2006. Accessed June 14, 2006.
-
(2006)
Adverse Health Events Reporting Law: Minnesota's 27 Reportable Events
-
-
-
11
-
-
0016862109
-
Kidney puncture on the wrong side - Caution
-
Kidney puncture on the wrong side - caution [in Swedish]. Lakartidningen. 1975;72:793.
-
(1975)
Lakartidningen
, vol.72
, pp. 793
-
-
-
12
-
-
0016862860
-
Ureter surgery of the wrong side
-
Ureter surgery of the wrong side [in Swedish]. Tidskr Sver Sjukskot. 1975;42:62.
-
(1975)
Tidskr Sver Sjukskot
, vol.42
, pp. 62
-
-
-
13
-
-
0017319372
-
Femur operation on the wrong side
-
Femur operation on the wrong side [in Swedish]. Lakartidningen. 1976;73:1327.
-
(1976)
Lakartidningen
, vol.73
, pp. 1327
-
-
-
14
-
-
0017769947
-
Hip surgery on the wrong side
-
Hip surgery on the wrong side [in Swedish]. Vardfacket. 1977;1:68.
-
(1977)
Vardfacket
, vol.1
, pp. 68
-
-
-
15
-
-
0028320520
-
Erroneous placement of side indicators of brain CT
-
Altinors N. Erroneous placement of side indicators of brain CT. AJNR Am J Neuroradiol. 1994;15:197.
-
(1994)
AJNR Am J Neuroradiol
, vol.15
, pp. 197
-
-
Altinors, N.1
-
16
-
-
0037395699
-
Wrong-side surgery: Systems for prevention
-
Bernstein M. Wrong-side surgery: systems for prevention. Can J Surg. 2003;46:144-146.
-
(2003)
Can J Surg
, vol.46
, pp. 144-146
-
-
Bernstein, M.1
-
18
-
-
0036551264
-
Side markings of the neonatal chest X-ray: Two legal cases of pneumothorax side mix up
-
Finnbogason T, Bremmer S, Ringertz H. Side markings of the neonatal chest X-ray: two legal cases of pneumothorax side mix up. Eur Radiol. 2002;12:938-941.
-
(2002)
Eur Radiol
, vol.12
, pp. 938-941
-
-
Finnbogason, T.1
Bremmer, S.2
Ringertz, H.3
-
20
-
-
0038380851
-
No defense for wrong-site surgery
-
Levy DA. No defense for wrong-site surgery. Am Acad Orthop Surg Bull. 1998;46(3). http://www2.aaos.org/aaos/archives/bulletin/jun98/legalcol.htm. Accessed November 28, 2005.
-
(1998)
Am Acad Orthop Surg Bull
, vol.46
, Issue.3
-
-
Levy, D.A.1
-
23
-
-
0025439646
-
Operation on the wrong side: An avoidable adverse event
-
Wender SS Jr. Operation on the wrong side: an avoidable adverse event. J Fla Med Assoc. 1990;77:585-586.
-
(1990)
J Fla Med Assoc
, vol.77
, pp. 585-586
-
-
Wender Jr., S.S.1
-
24
-
-
33751204055
-
-
December 31, JCAHO Web site
-
Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistics. December 31, 2005. JCAHO Web site. http://www.jointcommission. org/SentinelEvents/Statistics/. Accessed June 14, 2006.
-
(2005)
Sentinel Event Statistics
-
-
-
25
-
-
17044444151
-
Wrong-site surgery
-
Cowell HR. Wrong-site surgery [editorial]. J Bone Joint Surg Am. 1998;80:463.
-
(1998)
J Bone Joint Surg Am
, vol.80
, pp. 463
-
-
Cowell, H.R.1
-
26
-
-
0037315540
-
Incidence of wrong-site surgery among hand surgeons
-
Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85-A:193-197.
-
(2003)
J Bone Joint Surg Am
, vol.85 A
, pp. 193-197
-
-
Meinberg, E.G.1
Stern, P.J.2
-
27
-
-
0034681861
-
Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems
-
Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759-763.
-
(2000)
BMJ
, vol.320
, pp. 759-763
-
-
Barach, P.1
Small, S.D.2
-
28
-
-
0029066463
-
Incidence of adverse drug events and potential adverse drug events: Implications for prevention
-
Bates DW, Cullen DJ, Laird N, et al; ADE Prevention Study Group. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34.
-
(1995)
JAMA
, vol.274
, pp. 29-34
-
-
Bates, D.W.1
Cullen, D.J.2
Laird, N.3
-
29
-
-
33748780247
-
-
National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Web site
-
Public data files. National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Web site. http://www.npdb-hipdb.com/publicdata.html. Accessed November 28, 2005.
-
Public Data Files
-
-
-
30
-
-
0037448346
-
Risk factors for retained instruments and sponges after surgery
-
Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229-235.
-
(2003)
N Engl J Med
, vol.348
, pp. 229-235
-
-
Gawande, A.A.1
Studdert, D.M.2
Orav, E.J.3
Brennan, T.A.4
Zinner, M.J.5
-
31
-
-
0041843748
-
Patient safety and blood transfusion: New solutions
-
Dzik WH, Corwin H, Goodnough LT, et al. Patient safety and blood transfusion: new solutions. Transfus Med Rev. 2003;17:169-180.
-
(2003)
Transfus Med Rev
, vol.17
, pp. 169-180
-
-
Dzik, W.H.1
Corwin, H.2
Goodnough, L.T.3
-
32
-
-
0033787643
-
Transfusion errors in New York State: An analysis of 10 years' experience
-
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion. 2000;40:1207-1213.
-
(2000)
Transfusion
, vol.40
, pp. 1207-1213
-
-
Linden, J.V.1
Wagner, K.2
Voytovich, A.E.3
Sheehan, J.4
-
33
-
-
33748789482
-
-
Florida Agency for Healthcare Administration Web site
-
AHCA. Florida Agency for Healthcare Administration Web site. 2003. http://www.fdhc.state.fl.us/. Accessed June 18, 2006.
-
(2003)
-
-
-
37
-
-
33645866776
-
Incidence, patterns, and prevention of wrong-site surgery
-
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353-358.
-
(2006)
Arch Surg
, vol.141
, pp. 353-358
-
-
Kwaan, M.R.1
Studdert, D.M.2
Zinner, M.J.3
Gawande, A.A.4
-
38
-
-
33748760767
-
-
National Center for Health Statistics Web site. Last reviewed February 7
-
Centers for Disease Control and Prevention. Inpatient procedures. National Center for Health Statistics Web site. Last reviewed February 7, 2006. http://www.cdc.gov/nchs/fastats/insurg.htm. Accessed June 28, 2006.
-
(2006)
Inpatient Procedures
-
-
-
39
-
-
84872354471
-
Ambulatory and inpatient procedures in the United States, 1996
-
Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998;(139):1-119. http://www.cdc.gov/nchs/ data/series/sr_13/sr13_139.pdf. Accessed June 29, 2006.
-
(1998)
Vital Health Stat 13
, Issue.139
, pp. 1-119
-
-
Owings, M.F.1
Kozak, L.J.2
-
40
-
-
33748772950
-
-
Motorola University, Motorola Inc Web site
-
FAQs. What is Six Sigma? Motorola University, Motorola Inc Web site. http://www.motorola.com/content.jsp?globalObjectId=3088. Accessed on June 14, 2006.
-
FAQs. What Is Six Sigma?
-
-
-
41
-
-
33748792426
-
-
Associated Press. April 17
-
Yamaguchi M. Medical errors outrage Japan. Associated Press. April 17, 1999. http://www2.gol.com/users/coynerhm/medical_errors_outrage_japan.htm. Accessed June 6, 2003.
-
(1999)
Medical Errors Outrage Japan
-
-
Yamaguchi, M.1
-
42
-
-
33748803772
-
Hospital pulls plug on the wrong patient
-
March 13, § A:2
-
Associated Press. Hospital pulls plug on the wrong patient. Toronto Star. March 13, 1995;§ A:2.
-
(1995)
Toronto Star
-
-
-
43
-
-
33748795950
-
Mom awarded $1 million over embryo mix-up
-
August 4, § B:4
-
Chiang H. Mom awarded $1 million over embryo mix-up. San Francisco Chronicle. August 4, 2004;§ B:4. http://sfgate.com/cgi-bin/article.cgi? file=/chronicle/archive/2004/08/04/BAGN382BII1.DTL. Accessed November 28, 2005.
-
(2004)
San Francisco Chronicle
-
-
Chiang, H.1
-
44
-
-
33748798364
-
License revoked for embryo mix-up
-
March 31, § B:4
-
Seligman K. License revoked for embryo mix-up. San Francisco Chronicle. March 31, 2005;§ B:4. http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/ 03/31/BAGIOC10PK1.DTL. Accessed November 28, 2005.
-
(2005)
San Francisco Chronicle
-
-
Seligman, K.1
-
45
-
-
33748807890
-
Wrong embryos implanted in three patients
-
October 29, Home news
-
Wright O. Wrong embryos implanted in three patients. The Times (London). October 29, 2002;Home news:4.
-
(2002)
The Times (London)
, pp. 4
-
-
Wright, O.1
-
47
-
-
33748769938
-
Radiation given to wrong patient
-
December 2, section A
-
Radiation given to wrong patient. The Gazette. December 2, 1992;section A:3.
-
(1992)
The Gazette
, pp. 3
-
-
-
49
-
-
33748776429
-
Mix-up leads wrong patient to heart surgery
-
August 4, § B
-
Gentry C. Mix-up leads wrong patient to heart surgery. St Petersburg Times. August 4, 1990;§ B:1.
-
(1990)
St Petersburg Times
, pp. 1
-
-
Gentry, C.1
-
50
-
-
4244104407
-
Surgeon operates on wrong patient
-
July 11, § A
-
Rosen M. Surgeon operates on wrong patient. St Petersburg Times. July 11, 1998;§ A:1.
-
(1998)
St Petersburg Times
, pp. 1
-
-
Rosen, M.1
-
51
-
-
33748771868
-
Girl in transplant mix-up dies after two weeks
-
February 23, sect; 1
-
Archibold RC. Girl in transplant mix-up dies after two weeks. New York Times. February 23, 2003;§ 1:18.
-
(2003)
New York Times
, pp. 18
-
-
Archibold, R.C.1
-
52
-
-
4243983343
-
Wrong girl gets tonsils taken out
-
December 23, section B
-
Mishra R. Wrong girl gets tonsils taken out. Boston Globe. December 23, 2000; section B:1.
-
(2000)
Boston Globe
, pp. 1
-
-
Mishra, R.1
-
53
-
-
0036599806
-
Preoperative signing of the incision site in orthopaedic surgery in Canada
-
Furey A, Stone C, Martin R. Preoperative signing of the incision site in orthopaedic surgery in Canada. J Bone Joint Surg Am. 2002;84-A:1066-1068.
-
(2002)
J Bone Joint Surg Am
, vol.84 A
, pp. 1066-1068
-
-
Furey, A.1
Stone, C.2
Martin, R.3
-
58
-
-
4243482495
-
The doctor's world: The wrong foot, and other tales of surgical error
-
December 11, § F
-
Altman LK. The doctor's world: the wrong foot, and other tales of surgical error. New York Times. December 11, 2001;§ F:1.
-
(2001)
New York Times
, pp. 1
-
-
Altman, L.K.1
-
59
-
-
33748772396
-
The tumor is on the left, right? seeking ways to reduce operating room errors
-
April 1, § 1
-
Steinhauer J. The tumor is on the left, right? seeking ways to reduce operating room errors. New York Times. April 1, 2001;§ 1:27.
-
(2001)
New York Times
, pp. 27
-
-
Steinhauer, J.1
-
60
-
-
33748761277
-
-
Washington University in St Louis, School of Medicine Web site August 9
-
Ericson G. Smart wristband designed to prevent wrong-site surgery. Washington University in St Louis, School of Medicine Web site. August 9, 2005. http://mednews.wustl.edu/news/page/normal/5547.html. Accessed November 28, 2005.
-
(2005)
Smart Wristband Designed to Prevent Wrong-site Surgery
-
-
Ericson, G.1
-
62
-
-
33748786141
-
-
SURGICHIP Inc Web site
-
SURGICHIP. SURGICHIP Inc Web site. http://www.surgichip.com/. Accessed November 27, 2005.
-
-
-
-
63
-
-
0015231889
-
Mental rotation of three-dimensional objects
-
Shepard RN, Metzler J. Mental rotation of three-dimensional objects. Science. 1971;171:701-703.
-
(1971)
Science
, vol.171
, pp. 701-703
-
-
Shepard, R.N.1
Metzler, J.2
-
64
-
-
0028318181
-
Transfusion errors: Causes and effects
-
Linden JV, Kaplan HS. Transfusion errors: causes and effects. Transfus Med Rev. 1994;8:169-183.
-
(1994)
Transfus Med Rev
, vol.8
, pp. 169-183
-
-
Linden, J.V.1
Kaplan, H.S.2
-
65
-
-
0036904946
-
Human factors engineering and patient safety
-
Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care. 2002;11:352-354.
-
(2002)
Qual Saf Health Care
, vol.11
, pp. 352-354
-
-
Gosbee, J.1
-
66
-
-
0029982996
-
An automated system for bedside verification of the match between patient identification and blood unit identification
-
Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient identification and blood unit identification. Transfusion. 1996;36:216-221.
-
(1996)
Transfusion
, vol.36
, pp. 216-221
-
-
Jensen, N.J.1
Crosson, J.T.2
-
67
-
-
0025816639
-
Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice
-
Wenz B, Burns ER. Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice. Transfusion. 1991;31:401-403.
-
(1991)
Transfusion
, vol.31
, pp. 401-403
-
-
Wenz, B.1
Burns, E.R.2
-
68
-
-
0034783544
-
Reporting of near-miss events for transfusion medicine: Improving transfusion safety
-
Callum JL, Kaplan HS, Merkley LL, et al. Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion. 2001;41:1204-1211.
-
(2001)
Transfusion
, vol.41
, pp. 1204-1211
-
-
Callum, J.L.1
Kaplan, H.S.2
Merkley, L.L.3
-
69
-
-
0034060619
-
Comparing near misses with actual mistransfusion events: A more accurate reflection of transfusion errors
-
Ibojie J, Urbaniak SJ. Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors. Br J Haematol. 2000;108:458-460.
-
(2000)
Br J Haematol
, vol.108
, pp. 458-460
-
-
Ibojie, J.1
Urbaniak, S.J.2
-
70
-
-
0036594081
-
Incident reporting: Science or protoscience? ten years later
-
Kaplan H, Barach P. Incident reporting: science or protoscience? ten years later. Qual Saf Health Care. 2002;11:144-145.
-
(2002)
Qual Saf Health Care
, vol.11
, pp. 144-145
-
-
Kaplan, H.1
Barach, P.2
-
71
-
-
0027674018
-
The Australian Incident Monitoring Study: Errors, incidents and accidents in anaesthetic practice
-
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study: errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21:506-519.
-
(1993)
Anaesth Intensive Care
, vol.21
, pp. 506-519
-
-
Runciman, W.B.1
Sellen, A.2
Webb, R.K.3
-
72
-
-
0036831008
-
Patient safety first alert - Implementing a correct site surgery policy and procedure
-
Patient safety first alert - implementing a correct site surgery policy and procedure. AORN J. 2002;76:785-788.
-
(2002)
AORN J
, vol.76
, pp. 785-788
-
-
-
73
-
-
33748782669
-
-
AORN Web site. February
-
AORN position statement on correct site surgery. AORN Web site. February 2003. http://www.aorn.org/About/positions/correctsite.htm. Accessed November 28, 2005.
-
(2003)
AORN Position Statement on Correct Site Surgery
-
-
-
74
-
-
0036830959
-
Ensuring correct site surgery
-
Scheidt RC. Ensuring correct site surgery. AORN J. 2002;76:770-782.
-
(2002)
AORN J
, vol.76
, pp. 770-782
-
-
Scheidt, R.C.1
-
78
-
-
0038585776
-
Statement on ensuring correct patient, correct site, and correct procedure surgery
-
American College of Surgeons. Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg. 2002;87(12):26.
-
(2002)
Bull Am Coll Surg
, vol.87
, Issue.12
, pp. 26
-
-
-
79
-
-
33748801091
-
-
Washington, DC: Dept of Veterans Affairs, Veterans Health Administration
-
Department of Veterans Affairs, Veterans Health Administration. Ensuring Correct Surgery, VHA Directive 2002-070. Washington, DC: Dept of Veterans Affairs, Veterans Health Administration; 2002.
-
(2002)
Ensuring Correct Surgery, VHA Directive 2002-070
-
-
-
80
-
-
33748763172
-
-
North American Spine Society Web site
-
North American Spine Society. Prevention of wrong-site surgery: sign, mark and x-ray (SMaX). North American Spine Society Web site. 2001. http://www.spine.org/smax.cfm. Accessed November 28, 2005.
-
(2001)
Prevention of Wrong-site Surgery: Sign, Mark and X-ray (SMaX)
-
-
-
82
-
-
33748760487
-
-
Cochrane Collaboration. http://www3.interscience.wiley.com/cgi-bin/ mrwhome/106568753/HOME?CRETRY=1&SRETRY=0. Accessed June 20, 2006.
-
-
-
-
83
-
-
10344257193
-
Integrating patient safety into the clinical microsystem
-
Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical microsystem. Qual Saf Health Care. 2004;13(suppl 2):ii34-ii38.
-
(2004)
Qual Saf Health Care
, vol.13
, Issue.2 SUPPL.
-
-
Mohr, J.1
Batalden, P.2
Barach, P.3
-
84
-
-
0032033923
-
Some hopes and concerns regarding medical event-reporting systems: Lessons from the NASA Aviation Safety Reporting System
-
Billings CE. Some hopes and concerns regarding medical event-reporting systems: lessons from the NASA Aviation Safety Reporting System. Arch Pathol Lab Med. 1998;122:214-215.
-
(1998)
Arch Pathol Lab Med
, vol.122
, pp. 214-215
-
-
Billings, C.E.1
-
87
-
-
22144451148
-
The role of teamwork in the professional education of physicians: Current status and assessment recommendations
-
Baker DP, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Patient Saf. 2005;31:185-202.
-
(2005)
Jt Comm J Qual Patient Saf
, vol.31
, pp. 185-202
-
-
Baker, D.P.1
Battles, J.2
King, H.3
Salas, E.4
Barach, P.5
-
88
-
-
0028097184
-
Error in medicine
-
Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.
-
(1994)
JAMA
, vol.272
, pp. 1851-1857
-
-
Leape, L.L.1
-
89
-
-
0029384423
-
The incident reporting system does not detect adverse drug events: A problem for quality improvement
-
Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21:541-548.
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(1995)
Jt Comm J Qual Improv
, vol.21
, pp. 541-548
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Cullen, D.J.1
Bates, D.W.2
Small, S.D.3
Cooper, J.B.4
Nemeskal, A.R.5
Leape, L.L.6
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