-
psnet.ahrq.gov/node/45268/psn-pdf
September 27, 2016 - implementation study,
investigators used sponges embedded with radio frequency detection (RFD) in emergency surgeries
-
psnet.ahrq.gov/node/41958/psn-pdf
April 17, 2013 - psnet.ahrq.gov/issue/surgical-never-events-united-states
More than a decade ago, stories of wrong site surgeries
-
psnet.ahrq.gov/node/39893/psn-pdf
November 02, 2010 - However, this study finds that the volume–outcome relationship is limited to a few specific
surgeries
-
psnet.ahrq.gov/node/40145/psn-pdf
November 14, 2011 - This analysis of more than 6 million inpatient
surgeries identified risk factors for the development
-
psnet.ahrq.gov/node/38014/psn-pdf
March 02, 2011 - However, manual counting has
been criticized as ineffective and leading to prolonged surgeries.
-
psnet.ahrq.gov/node/46774/psn-pdf
April 12, 2019 - The number of surgeries in which a handoff occurred increased over time
during the 6-year study period
-
psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Universal Protocol was designed to engage institutions in implementing a standardized
approach to surgeries … In fact, The Joint Commission sentinel event statistics
database reported 1072 wrong-site surgeries … widely when examining the literature and
accessible databases, ranging from 0.09 to 4.5 per 10,000 surgeries … Definitions and Examples of Wrong-Site Surgeries.(2)
Type Definition Example
Wrong Site
All surgical
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psnet.ahrq.gov/issue/twenty-tips-help-prevent-medical-errors-children
December 24, 2008 - parents on how to help their children avoid medical errors pertaining to medicine, hospital stays, surgeries
-
psnet.ahrq.gov/issue/reused-devices-surgerys-deadly-suspects
January 04, 2006 - exposed to a rare brain disease after contaminated surgical instruments were used during their brain surgeries
-
psnet.ahrq.gov/node/845361/psn-pdf
March 29, 2023 - standardized-marking-procedure-ent-operations-prevent-wrong-site-
surgery-development
Although wrong-site surgeries
-
psnet.ahrq.gov/node/46732/psn-pdf
June 07, 2018 - sages-fundamental-use-surgical-energy-program-fuse-history-development-and-purpose
https://psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought
-
psnet.ahrq.gov/node/41626/psn-pdf
August 29, 2012 - superficial surgical site infections; operative time was
approximately 25 minutes longer for resident surgeries
-
psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
April 28, 2021 - This commentary explores strategies to prevent surgical fires, wrong-site surgeries , and retained surgical
-
psnet.ahrq.gov/node/36315/psn-pdf
July 10, 2008 - A prior study indicated a rate of
approximately 1 case per 112,000 surgeries, but WSPEs may occur in
-
psnet.ahrq.gov/node/34063/psn-pdf
September 18, 2011 - risk-factors-retained-instruments-and-sponges-after-surgery
This case-control study discovered that emergency surgeries
-
psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
October 19, 2022 - The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries
-
psnet.ahrq.gov/issue/safety-numbers-hospital-performance-leapfrogs-surgical-volume-standard-based-results-2019
June 21, 2023 - deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries
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psnet.ahrq.gov/issue/second-opinion-consult-computer
June 03, 2020 - March 4, 2020
Six ways to lower errors—and unnecessary surgeries—in radiology exams.
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - Medicare beneficiaries from 2015 to 2020, researchers found that female patients undergoing high-risk surgeries … Medicare beneficiaries from 2015 to 2020, researchers found that female patients undergoing high-risk surgeries … This cross-sectional study at one Danish hospital found that patients whose surgeries were canceled reported
-
psnet.ahrq.gov/node/39123/psn-pdf
April 30, 2014 - issue/incorrect-surgical-procedures-within-and-outside-operating-room
Wrong-patient and wrong-site surgeries