Achieving the national quality forum's "never events": Prevention of wrong site, wrong procedure, and wrong patient operations

Annals of Surgery

Volumn 245, Issue 4, 2007, Pages 526-532

  Michaels, Robert K ^a   Makary, Martin A ^a,c   Dahab, Yasser ^a   Frassica, Frank J ^a   Heitmiller, Eugenie ^a   Rowen, Lisa C ^a   Crotreau, Richard ^b   Brem, Henry ^a   Pronovost, Peter J ^a  

^a DEPARTMENT OF PATHOLOGY   (United States)

^b Joint Commission   (United States)

^c NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACCREDITATION; HEALTH CARE ORGANIZATION; HEALTH CARE POLICY; HEALTH PRACTITIONER; HEALTH PROGRAM; HUMAN; MEDICAL LITERATURE; MEDICAL TECHNOLOGY; MEDLINE; PRIORITY JOURNAL; QUALITATIVE ANALYSIS; REVIEW; RISK FACTOR; SAFETY; SCIENCE; SURGICAL TECHNIQUE;

CANADA; CLINICAL PROTOCOLS; HUMANS; JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS; MEDICAL ERRORS; RISK FACTORS; SAFETY; SAFETY MANAGEMENT; SOCIETIES, MEDICAL; SURGERY DEPARTMENT, HOSPITAL; SURGICAL PROCEDURES, OPERATIVE; TECHNOLOGY, MEDICAL; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS;

EID: 34147141336     PISSN: 00034932     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.sla.0000251573.52463.d2     Document Type: Review

References (21)

1. Makary MA, Sexton JB, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243:628-632.
2. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA. 2006;296:696-699.
3. Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Saf. 2006;32:102-108.
4. Pronovost PJ, Holzmueller CG, Sexton JB, et al. How will we know patients are safer? An organization-wide approach to measuring and improving patient safety. Crit Care Med. 2006;34:1988-1995.
5. Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in healthcare organizations. Health Serv Res. 2006;41:1599-1617.
6. Edmonds CR, Liguori GA, Stanton MA. Two cases of a wrong-site peripheral nerve block and a process to prevent this complication. Reg Anesth Pain Med. 2005;30:99-103.
7. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert. A follow-up review of wrong site surgery. Report No. 24;2001. Available at: http://www.jcaho.org.
8. Wachter RM, McDonald KM. Making health care safer: a critical analysis of patient safety practices [Report Evidence Report/Technology Assessment No. 43]. Rockville, MD: Agency for Healthcare Research and Quality, 2001.
9. Cowell HR. Wrong-site surgery. J Bone Joint Surg Am. 1998;80:463.
10. Meinberg RG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85:193-197.
11. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877-884.
12. Cronin G, Ringus V, Sigle G, et al. Sterility of surgical site marking. J Bone Joint Surg Am. 2005;87:2193-2195.
13. Surowiecki J. The Wisdom of Crowds: Why the Many Are Smarter Than the Few and How Collective Wisdom Shapes Business, Economics, Societies and Nations. New York: Random House, 2004.
14. Veterans Health Administration. Ensuring correct surgery and invasive procedures. VHA Directive 2004-28. July 25, 2004. Available at: http://www1. va.gov/vhapublications/ViewPublication.asp?pub_ID=1106. Accessed September 14, 2006.
15. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-75.
16. Makary MA, Holzmueller CG, Thompson DA, et al. Operating room briefings: working on the same page. Jt Comm J Qual Saf. 2006;32:351-355.
17. Food and Drug Administration. FDA clears new surgical marker; Uses RFID to protect patients. FDA Talk Paper [serial online]. November 19, 2004; Available from: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01326. html. Accessed April 11, 2006.
18. Han Y, Carcillo J, Venkataraman S, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116:1506-1512.
19. McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144:510-516.
20. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin. 2005;21:1-19.
21. Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353-358.