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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
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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/lost-voice
March 21, 2007 - surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries
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psnet.ahrq.gov/issue/risks-are-high-low-volume-hospitals
September 12, 2012 - This news article reports an independent analysis of patient risk at hospitals that provide surgeries
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psnet.ahrq.gov/issue/plan-aims-cut-hospital-deaths
August 28, 2019 - July 10, 2019
Surgeons must tell patients of double-booked surgeries, new guidelines
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - At minimum, this meta-analysis
argues for continued clinical supervision of surgeries and invasive procedures
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psnet.ahrq.gov/node/40963/psn-pdf
November 30, 2011 - CPOE), physician staffing in intensive care units (ICU), evidence-based referrals for
high-mortality surgeries
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psnet.ahrq.gov/node/40013/psn-pdf
July 24, 2011 - patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-
wrong-site
Wrong-site surgeries
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psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
September 27, 2023 - The institution did not experience any wrong-site surgeries during that time.
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psnet.ahrq.gov/issue/equipment-related-incidents-operating-room-analysis-occurrence-underlying-causes-and
February 14, 2024 - Faulty or missing equipment resulted in operating room delays in nearly 16% of scheduled surgeries, in
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psnet.ahrq.gov/issue/utmc-nurse-tossed-out-kidney-ruined-it-national-experts-say-error-rare
August 07, 2024 - August 21, 2013
Doctors perform thousands of unnecessary surgeries.
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psnet.ahrq.gov/issue/some-hospitals-call-911-save-their-patients
January 18, 2023 - May 16, 2007
Surgeons must tell patients of double-booked surgeries, new guidelines say
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psnet.ahrq.gov/issue/shelhigh-inc-implantable-medical-devices
April 08, 2020 - August 11, 2010
Quality of Care in Cranial Implant Surgeries at James A.
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psnet.ahrq.gov/issue/frederick-mothers-burning-inspires-daughters-activism
June 24, 2020 - July 8, 2009
Fires during surgeries a bigger risk than thought.
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - net reimbursements for patients
who experienced surgical complications compared with patients whose surgeries
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psnet.ahrq.gov/issue/doctors-say-they-need-protection-apologize
August 24, 2016 - Cite
Related Resources From the Same Author(s)
5 cataract surgeries
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psnet.ahrq.gov/issue/model-patient-how-simulators-are-changing-way-doctors-are-trained
August 24, 2016 - October 19, 2011
Surgeons must tell patients of double-booked surgeries, new guidelines
-
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/issue/impact-resident-participation-surgical-operations-postoperative-outcomes-national-surgical
November 16, 2022 - superficial surgical site infections; operative time was approximately 25 minutes longer for resident surgeries
-
psnet.ahrq.gov/issue/impact-rvu-based-compensation-patient-safety-outcomes-outpatient-otolaryngology-procedures
October 19, 2022 - incidence of adverse outcomes, including postoperative hospitalizations, infections , unplanned return surgeries