Preventive Measures for Wrong Site, Wrong Person, and Wrong Procedure Error in the Perioperative Setting

Perioperative Nursing Clinics

Volumn 3, Issue 4, 2008, Pages 383-393

  McNamara, Sharon A ^a  

^a WAKEMED HEALTH AND HOSPITALS   (United States)

Author keywords

Adverse events; Preventable adverse events; Wrong patient surgery; Wrong procedure surgery; Wrong side surgery; Wrong site surgery

Indexed keywords

EID: 55749095233     PISSN: 15567931     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.cpen.2008.08.008     Document Type: Review

References (40)

1. Canadian Orthopedic Association Committee on Practice and Economics. Position paper on wrong-sided surgery in orthopedics. Winnipeg, Manitoba, Canada: Canadian Orthopedic Association; 1994.
2. Canale T.S. Wrong site surgery a preventable complication. Clin Orthop Relat Res 433 (2005) 26
3. American Academy of Orthopedic Surgeons. Advisory statement on wrong-site surgery. Available at:. www.aaos.org Accessed April 27, 2008
4. Joint Commission International Center for Patient Safety. Sentinel events alerts. Issue 6. Lessons learned: wrong site surgery. Available at:. www.jcipatientsafety.org/14791/ Accessed May 8, 2008
5. Kohn L.T., Corrigan J.M., and Donaldson M.S. To err is human building a safer health system (2000), National Academy Press, Washington, DC
6. Gaba D., Howard S.K., and Fish K. Crisis management in anesthesiology (1994), Churchill-Livingston, NY (NY)
7. Brennan T.A., Leape L., Laird N.M., et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard medical practice study I. N Engl J Med 324 (1991) 370-376
8. Wong D., Mayer T., Watters W., et al. Prevention of wrong site surgery: sign, mark and x-ray (SMaX) (2001), North American Spine Society, LaGrange, IL. Available at: www.spine.org/smax.cfm Accessed April 27, 2008
9. Committee on Quality of Health Care in America Institute of Medicine. Crossing the quality chasm a new health system for the 21st century. Washington, DC: National Academy Press; p. 5-6.
10. Association of Registered periOperative Nurses (AORN). Correct site surgery tool kit building a safer tomorrow. Available at:. www.aorn.org Accessed April 25, 2008
11. Joint Commission International Center for Patient Safety. International patient safety goals created. Available at:. www.jcipatientsafety.org/show.asp?durki=11753 Accessed April 8, 2008
12. Council on Surgical and Perioperative Safety. CSPS core principles. Available at:. www.cspsteam.org/education2.html Accessed May 14, 2008
13. World Health Organization. Safe surgery saves lives initiative. Available at:. www.who.int/patientsafety/challenge/safe.surgery/en/index.html Accessed May 7, 2008
14. The Joint Commission. Performance of correct procedure at correct body site. Patient Safety Solutions 1 4 (2007). Available at: www.thejointcommission.org Accessed May 12, 2008
15. Clarke J.R., Johnston J., and Finley E.D. Getting surgery right. Ann Surg 246 3 (2007) 397
16. Manuel B.M., and Nora P.F. Surgical patient safety essential is information for surgeons in today's environment (2004), American College of Surgeons, Chicago, IL p. 112
17. Seiden S.C., and Barach P. Wrong-side/wrong-procedure, and wrong-patient adverse events: are they preventable?. Arch Surg 141 (2006) 931-939
18. Cowell H.R. Wrong-site surgery. J Bone Joint Surg Am 80 (1998) 463
19. Michaels R.K., Makary M.A., Yasser D., et al. Achieving the national quality forum's "never events" prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg 245 4 (2007) 526-532
20. Joint Commission on Accreditation of Health Care Organizations. Sentinel event alert: a follow-up review of wrong site surgery. Report no. 24. Available at:. www.thejointcommission.org Accessed May 17, 2008
21. Meinberg R.G., and Stern P.J. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am 85 (2003) 193-197
22. Understanding patient safety: a Q&A with Robert Wachter, MD. Infection Control Today 2008;3:54.
23. Kwan M.R., Studdert D.M., Zinner M.J., et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 141 (2006) 353-358
24. The Joint Commission. Compliance strategies for the universal protocol (2007), Joint Commission Resources, Chicago, IL p. 11-7
25. The Joint Commission, Joint Commission International, World Health organization. Performance of correct procedure at correct body site. Patient Safety Solutions 1 4 (2007)
26. Cronen G., Vytantas R., and Sogle G. Sterility of surgical site marking. J Bone Joint Surg Am 87 10 (2005) 2193-2195
27. Norton E. Implementing the universal protocol hospital-wide. AORN J 85 6 (2007) 1187-1197
28. Bennett C. Timeout: it's easy as apple pie!. OR Manager 23 7 (2007) 14
29. Hylka S.C. Ensuring consistent time-out in a system. OR Manager 22 7 (2006) 10
30. Insights into preventing wrong-site surgery. Available at:. www.psa.state.pa.us Accessed May 14, 2008
31. Landmesser S. A time-out tool helps improve compliance at the patient's bedside. OR Manager 23 12 (2007) 5
32. Charlton N. Time out: the surgical pause that counts. AORN J 80 6 (2004) 1121-1122
33. Bloomfield C. Scripting for success. AORN J 83 5 (2006) 1127-1128
34. Page L. System marks new methods of preventing wrong-site surgery. Mater Manag Health Care (2006) 55-56
35. Tablac A. Doctor's invention aims to prevent surgical mishaps. Available at:. www.stltoday.com Accessed November 5, 2007
36. Dattilo E., and Constantino R.E. Root cause analysis and nursing management responsibilities in wrong-site surgery. Dimens Crit Care Nurs 25 5 (2006) 221-225
37. The Joint Commission. Root cause analysis matrix minimum scope of root cause analysis for specific types of sentinel events: October 2005. Available at:. www.jointcommission.org Accessed June 1, 2008
38. Andrus C.H., Villasenor E.G., Kettelle J.B., et al. To err is human: uniformly reporting medical errors and near misses, a naive, costly, and misdirected goal. J Am Coll Surg 196 6 (2003) 914
39. Pronovost P.J., Miller M.R., and Wachter R.M. Tracking progress in patient safety: an elusive target. JAMA 296 (2006) 696-699
40. Provonost P.J., Holzmueller C.G., Martinez E., et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Saf 32 (2006) 102-108