Surgical never events in the United States
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013 Apr;153(4):465-72. doi: 10.1016/j.surg.2012.10.005. Epub 2012 Dec 17. PMID: 23257079.
The Joint Commission Universal Protocol
Association of periOperative Registered Nurses (AORN)
Actions to Prevent Wrong-Patient, Wrong-Site, Wrong-Procedure Events. Wrong Site Surgery Resources [Internet]. 8/28/2020.
The American Academy of Orthopaedic Surgeons (AAOS)
Information Statement: Surgical Site and Procedure Confirmation. Information Statement 1043: AAOS; 2015. p. 1-3.
289 Wrong-site surgery in medicine and dermatology: Analysis of data from the Joint Commission and from the Patient Safety Authority of Pennsylvania (J.S.Taylor, R.A.Yonash, M.A.Taylor, Journal of Investigative Dermatology, 2021 May.)
Abstract article authored by a Consultant Dermatologist and Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine along with Patient Safety Authority staff related to dermatological wrong site events. The virtual meeting abstract was presented at the May 2021 Society for Investigative Dermatology Meeting and published in the Journal of Investigative Dermatology.
Wrong-Site Nerve Blocks: 10 yr Experience in a Large Multihospital Health-Care System (Hudson ME, Chelly JE, Lichter JR. Br J Anaesth. 2015 Mar 4. [Epub ahead of print].)
This study sought to quantify the incidence of wrong-site blocks and examine some of their associated risk factors. Using quality-improvement and billing data, the authors quantified the total number of blocks and wrong-site blocks occurring between July 1, 2002, and June 30, 2012, within the University of Pittsburgh Medical Center Health System.
Is Your Office Helping You Prevent Wrong Site Surgery? (Clarke JR. Bull Am Coll Surg 2014 Apr;99[4]:28-31.)
The Pennsylvania Patient Safety Authority clinical director authored this article about the effects of miscommunication between the surgeon's office and the operating suite. It offers recommendations for ensuring that the information communicated is correct. The article was published in the April 2014 issue of the Bulletin of the American College of Surgeons.
Wrong Site Surgery Near Misses and Actual Occurrences (Blanco M, Clarke JR, Martindell D. AORN J 2009 Aug;90[2]:215-22.)
Pennsylvania Patient Safety Authority analysts authored this article about analysis of aggregrate wrong-site surgery data collected from August 2007 to August 2008 using a common analysis form. The article was published in the August 2009 issue of AORN Journal.
Wrong-Site Surgery: Can We Prevent It? (Clarke JR, Johnston J, Blanco M, Martindell DP. Adv Surg 2008;42:13-31.)
Pennsylvania Patient Safety Authority analysts authored this article about the how the incidence of wrong-site surgery is great enough that it is a significant risk for many surgeons during their professional careers. But, it is an event that should never happen. The article was published in a 2008 issue of Advances in Surgery.
Getting Surgery Right (Clarke JR, Johnston J, Finley ED. Ann Surg 2007 Sep;246[3]:395-403.)
Pennsylvania Patient Safety Authority analysts authored this article, a detailed scientific analysis of the Authority's experience, which published in the September 2007 issue of the Annals of Surgery.
World Health Organization's Safe Surgery Web Page
WHO's surgical safety checklist and implementation manual are included among the resources on this WHO Web page.
Minnesota Hospital Association's Time Out Surgical Checklist Toolkit
The Minnesota Hospital Association's Surgery and Procedures Web page includes resources relevant to wrong-site surgery.
