-
1
-
-
84872597459
-
-
Available at: Accessed October 29, 2011
-
The Joint Commission. Sentinel Event. Stat 2011;30. Available at: www.jointcommission.org/assets/1/18/3Q2011-SE-Stats-Summary.pdf. Accessed October 29, 2011.
-
(2011)
Sentinel Event. Stat
, pp. 30
-
-
-
2
-
-
77949888551
-
Preventing wrong-site surgery
-
Rollins G. Preventing wrong-site surgery. Mater Manag Health Care 2010;19:20-2.
-
(2010)
Mater Manag Health Care
, vol.19
, pp. 20-22
-
-
Rollins, G.1
-
3
-
-
77954172225
-
Strategies for preventing wrong site, wrong procedure, wrong patient surgery
-
Guglielmi C, Canacari E, Moorman D, et al. Strategies for preventing wrong site, wrong procedure, wrong patient surgery. AORN J 2010;92:22-7.
-
(2010)
AORN J
, vol.92
, pp. 22-27
-
-
Guglielmi, C.1
Canacari, E.2
Moorman, D.3
-
4
-
-
73449143547
-
My life changing experience following wrong site surgery
-
McMonagle C. My life changing experience following wrong site surgery. J Perioper Pract 2009;19:324.
-
(2009)
J Perioper Pract
, vol.19
, pp. 324
-
-
McMonagle, C.1
-
5
-
-
67949086878
-
Wrong site surgery near misses and actual occurrences
-
Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J 2009;90:215-8, 221-2.
-
(2009)
AORN J
, vol.90
-
-
Blanco, M.1
Clarke, J.R.2
Martindell, D.3
-
7
-
-
77957280967
-
Breakthroughs on wrong site surgery
-
Patterson P. Breakthroughs on wrong site surgery. OR Manager 2010;26:20-2.
-
(2010)
OR Manager
, vol.26
, pp. 20-22
-
-
Patterson, P.1
-
8
-
-
79960209638
-
The extended surgical time-out: Does it improve quality and prevent wrong-site surgery?
-
Lee SL. The extended surgical time-out: does it improve quality and prevent wrong-site surgery? The Permanente Journal. 2010;14:19-23.
-
(2010)
The Permanente Journal
, vol.14
, pp. 19-23
-
-
Lee, S.L.1
-
9
-
-
78149478666
-
Effect of a comprehensive surgical safety system on patient outcomes
-
De Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
-
(2010)
N Engl J Med
, vol.363
, pp. 1928-1937
-
-
De Vries, E.N.1
Prins, H.A.2
Crolla, R.M.3
-
10
-
-
72749088675
-
Incorrect surgical procedures within and outside of the operating room
-
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg 2009;144:1028-34.
-
(2009)
Arch Surg
, vol.144
, pp. 1028-1034
-
-
Neily, J.1
Mills, P.D.2
Eldridge, N.3
-
11
-
-
81855206227
-
Incorrect surgical procedures within and outside of the operating room: A follow-up report
-
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg 2011;146:1235-9.
-
(2011)
Arch Surg
, vol.146
, pp. 1235-1239
-
-
Neily, J.1
Mills, P.D.2
Eldridge, N.3
-
12
-
-
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;141:353-7.
-
(2006)
Arch Surg
, vol.141
, pp. 353-357
-
-
Kwaan, M.R.1
Studdert, D.M.2
Zinner, M.J.3
Gawande, A.A.4
-
13
-
-
79952978326
-
Prevention of 3 'never events' in the operating room: Fires, gossypiboma, and wrong-site surgery
-
Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 'never events' in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov 2011;18:55-60.
-
(2011)
Surg Innov
, vol.18
, pp. 55-60
-
-
Zahiri, H.R.1
Stromberg, J.2
Skupsky, H.3
-
14
-
-
78149472117
-
Case records of the Massachusetts General Hospital: Case 34-2010: A 65-year-old woman with an incorrect operation on the left hand
-
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. N Engl J Med 2010;363:1950-7.
-
(2010)
N Engl J Med
, vol.363
, pp. 1950-1957
-
-
Ring, D.C.1
Herndon, J.H.2
Meyer, G.S.3
-
15
-
-
84857193971
-
-
Available at: Accessed October 29, 2011
-
The Joint Commission Universal Protocol. Hospital National Patient Safety Goals. Available at: www.jointcommission. org/assets/1/6/NPSG-EPs-Scoring-HAP- 20110706.pdf. Accessed October 29, 2011.
-
Hospital National Patient Safety Goals
-
-
-
16
-
-
77958550275
-
Wrong-site and wrong-patient procedures in the Universal Protocol era
-
Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the Universal Protocol era. Arch Surg 2010;145:978-84.
-
(2010)
Arch Surg
, vol.145
, pp. 978-984
-
-
Stahel, P.F.1
Sabel, A.L.2
Victoroff, M.S.3
-
17
-
-
34147141336
-
Achieving the national quality forum's 'never events': Prevention of wrong site, wrong procedure, and wrong patient operations
-
DOI 10.1097/01.sla.0000251573.52463.d2, PII 0000065820070400000006
-
Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum's 'never events.' Prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg 2007;245:526-32. (Pubitemid 46555654)
-
(2007)
Annals of Surgery
, vol.245
, Issue.4
, pp. 526-532
-
-
Michaels, R.K.1
Makary, M.A.2
Dahab, Y.3
Frassica, F.J.4
Heitmiller, E.5
Rowen, L.C.6
Crotreau, R.7
Brem, H.8
Pronovost, P.J.9
-
18
-
-
84970977742
-
Clarifying 'never events' and introducing 'always events.'
-
Lembitz A, Clarke TJ. Clarifying 'never events' and introducing 'always events.' Patient Safety in Surgery. 2009;3:26.
-
(2009)
Patient Safety in Surgery.
, vol.3
, pp. 26
-
-
Lembitz, A.1
Clarke, T.J.2
-
21
-
-
71949120993
-
No simple fix for fixation errors: Cognitive processes and their clinical applications
-
Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia 2010;65:61-9.
-
(2010)
Anaesthesia
, vol.65
, pp. 61-69
-
-
Fioratou, E.1
Flin, R.2
Glavin, R.3
-
22
-
-
36148951700
-
Surgical confusions in ophthalmology
-
DOI 10.1001/archopht.125.11.1515
-
Simon JW, Ngo Y, Khan S, Strogatz D. Surgical confusions in ophthalmology. Arch Ophthalmol 2007;125:1515-22. (Pubitemid 350106684)
-
(2007)
Archives of Ophthalmology
, vol.125
, Issue.11
, pp. 1515-1522
-
-
Simon, J.W.1
Ngo, Y.2
Khan, S.3
Strogatz, D.4
-
23
-
-
0041977450
-
The real reason people won't change
-
Kegan R, Lahey LL. The real reason people won't change. Harv Bus Rev 2001;79:84-92.
-
(2001)
Harv Bus Rev
, vol.79
, pp. 84-92
-
-
Kegan, R.1
Lahey, L.L.2
-
24
-
-
0035512001
-
Time as a catalyst for tension in nurse-surgeon communication
-
Espin SL, Lingard LA. Time as a catalyst for tension in nurse-surgeon communication. AORN J 2001;74:672-82.
-
(2001)
AORN J
, vol.74
, pp. 672-682
-
-
Espin, S.L.1
Lingard, L.A.2
-
25
-
-
33745206679
-
Persistence of unsafe practice in everyday work: An exploration of organizational and psychological factors constraining safety in the operating room
-
Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care 2006;15:165-70.
-
(2006)
Qual Saf Health Care
, vol.15
, pp. 165-170
-
-
Espin, S.1
Lingard, L.2
Baker, G.R.3
Regehr, G.4
-
28
-
-
5444227950
-
A cognitive aid for cardiac arrest: You can't use it if you don't know about it
-
Mills PD, DeRosier JM, Neily J, et al. A cognitive aid for cardiac arrest: you can't use it if you don't know about it. Jt Comm J Qual Saf 2004;30:488-96.
-
(2004)
Jt Comm J Qual Saf
, vol.30
, pp. 488-496
-
-
Mills, P.D.1
DeRosier, J.M.2
Neily, J.3
-
29
-
-
59449089116
-
A surgical safety checklist to reduce morbidity and mortality in a global population
-
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
-
(2009)
N Engl J Med
, vol.360
, pp. 491-499
-
-
Haynes, A.B.1
Weiser, T.G.2
Berry, W.R.3
-
30
-
-
78149311093
-
Briefing guide study: Preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program
-
Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg 2010;200:620-3.
-
(2010)
Am J Surg
, vol.200
, pp. 620-623
-
-
Paull, D.E.1
Mazzia, L.M.2
Wood, S.D.3
-
31
-
-
77958149840
-
Association between implementation of a medical team training program and surgical mortality
-
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700.
-
(2010)
JAMA
, vol.304
, pp. 1693-1700
-
-
Neily, J.1
Mills, P.D.2
Young-Xu, Y.3
-
33
-
-
0035486819
-
Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
-
Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.
-
(2001)
Jt Comm J Qual Improv
, vol.27
, pp. 522-532
-
-
Bagian, J.P.1
Lee, C.2
Gosbee, J.3
-
36
-
-
79953063589
-
Counter-heroism, common knowledge, and ergonomics: Concepts from aviation that could improve patient safety
-
Lewis GH, Vaithianathan R, Hockey PM, et al. Counter-heroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Q 2011;89:34-8.
-
(2011)
Milbank Q
, vol.89
, pp. 34-38
-
-
Lewis, G.H.1
Vaithianathan, R.2
Hockey, P.M.3
-
37
-
-
0034681819
-
Human error: Models and management
-
Reason J. Human error: models and management. BMJ 2000;320:768-70. (Pubitemid 30179429)
-
(2000)
British Medical Journal
, vol.320
, Issue.7237
, pp. 768-770
-
-
Reason, J.1
-
38
-
-
33845880922
-
An intervention to decrease catheter-related bloodstream infections in the ICU
-
DOI 10.1056/NEJMoa061115
-
Pronovost P, NeedhamD, Berneholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32. (Pubitemid 46021509)
-
(2006)
New England Journal of Medicine
, vol.355
, Issue.26
, pp. 2725-2732
-
-
Pronovost, P.1
Needham, D.2
Berenholtz, S.3
Sinopoli, D.4
Chu, H.5
Cosgrove, S.6
Sexton, B.7
Hyzy, R.8
Welsh, R.9
Roth, G.10
Bander, J.11
Kepros, J.12
Goeschel, C.13
-
39
-
-
81855195933
-
The case for training Veterans Administration frontline nurses in crew resource management
-
Sculli GL, Fore AM, Neily J, et al. The case for training Veterans Administration frontline nurses in crew resource management. JONA 2011;41:524-30.
-
(2011)
JONA
, vol.41
, pp. 524-530
-
-
Sculli, G.L.1
Fore, A.M.2
Neily, J.3
|