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psnet.ahrq.gov/issue/national-safety-effort-targets-perinatal-injuries November 10, 2010 - March 7, 2012 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
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psnet.ahrq.gov/issue/hospitals-look-improve-informed-consent-process November 10, 2010 - June 25, 2008 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
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psnet.ahrq.gov/issue/ibms-watson-learning-its-way-saving-lives October 18, 2017 - March 4, 2020 
 
 
 
 
 
 
 
 Six ways to lower errors—and unnecessary surgeries—in radiology exams. 
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psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses October 07, 2015 - March 4, 2020 
 
 
 
 
 
 
 
 Six ways to lower errors—and unnecessary surgeries—in radiology exams. 
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psnet.ahrq.gov/issue/ama-meeting-delegates-see-boosting-quality-care-duty March 07, 2012 - March 7, 2012 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
- 
                                        
psnet.ahrq.gov/issue/look-alike-sound-alike-oncology-medications July 02, 2008 - August 17, 2016 
 
 
 
 
 
 
 
 5 cataract surgeries, 5 people blinded: what went wrong? 
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psnet.ahrq.gov/issue/surgical-robot-examined-injuries April 27, 2016 - Related Resources From the Same Author(s) 
 
 
 
 
 
 
 Surgeons must tell patients of double-booked surgeries 
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psnet.ahrq.gov/issue/doctors-diagnosing-gets-technological-boost May 18, 2005 - August 28, 2019 
 
 
 
 
 
 
 
 Six ways to lower errors—and unnecessary surgeries—in radiology exams 
- 
                                        
psnet.ahrq.gov/issue/closing-safety-loop-auto-patient-id December 03, 2007 - June 16, 2010 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
- 
                                        
psnet.ahrq.gov/issue/walk-inside-have-surgery-it-safe January 02, 2008 - October 3, 2017 
 
 
 
 
 
 
 
 5 cataract surgeries, 5 people blinded: what went wrong? 
- 
                                        
psnet.ahrq.gov/issue/can-protecting-patients-be-made-recession-proof November 10, 2010 - June 25, 2008 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
- 
                                        
psnet.ahrq.gov/issue/diagnosis-doubled-over-pain May 16, 2007 - August 17, 2016 
 
 
 
 
 
 
 
 5 cataract surgeries, 5 people blinded: what went wrong? 
- 
                                        
psnet.ahrq.gov/issue/target-pill-bottles-now-convenient-and-cute October 05, 2016 - November 19, 2015 
 
 
 
 
 
 
 
 Awareness of patient safety grows with increased outpatient surgeries 
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psnet.ahrq.gov/issue/feds-reverse-course-will-release-hospital-mistake-data August 13, 2014 - September 6, 2017 
 
 
 
 
 
 
 
 Surgeons must tell patients of double-booked surgeries, new guidelines 
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psnet.ahrq.gov/issue/medication-safety-issue-brief-medication-reconciliation June 17, 2014 - June 17, 2014 
 
 
 
 
 
 
 
 Awareness of patient safety grows with increased outpatient surgeries. 
- 
                                        
psnet.ahrq.gov/issue/revealing-their-medical-errors-why-three-doctors-went-public November 10, 2010 - June 25, 2008 
 
 
 
 
 
 
 
 Sponges, surgical instruments miscounted in 13% of surgeries. 
- 
                                        
psnet.ahrq.gov/issue/arrogant-abusive-and-disruptive-and-doctor February 09, 2011 - August 17, 2016 
 
 
 
 
 
 
 
 5 cataract surgeries, 5 people blinded: what went wrong? 
- 
                                        
psnet.ahrq.gov/issue/how-can-we-save-next-victim January 23, 2008 - August 17, 2016 
 
 
 
 
 
 
 
 5 cataract surgeries, 5 people blinded: what went wrong? 
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt March 01, 2015 - S36. http://ncbi.nlm.nih.gov/pubmed/20407349
7
Contributing Factors & Root Causes
Most wrong-site surgeries … The Universal Protocol was designed to engage institutions in implementing a standardized approach to surgeries 
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psnet.ahrq.gov/issue/pain-wrong-site-surgery November 28, 2016 - May 21, 2013 
 
 
 
 
 
 
 
 Wrong body part, wrong patient surgeries continue despite new procedures