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- Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.Arch Surg. 2010; 145: 978-984
- Achieving the National Quality Forum's “Never Events”: prevention of wrong site, wrong procedure, and wrong patient operations.Ann Surg. 2007; 245: 526-532
- Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?.Arch Surg. 2006; 141: 931-939
- Retained foreign bodies.Adv Surg. 2008; 42: 183-191
- Risk factors for retained instruments and sponges after surgery.N Engl J Med. 2003; 348: 229-235
- Retained foreign bodies after surgery.J Surg Res. 2007; 138: 170-174
- Surgical “never events”: how common are adverse occurrences?.J Health Care Risk Mgmt. 2006; 26: 15-22
- Incidence and characteristics of potential and actual retained foreign object events in surgical patients.J Am Coll Surg. 2008; 207: 80-87
Centers for Medicare and Medicaid Services, CMS Office of Public Affairs. CMS improves patient safety for Medicare and Medicaid by addressing never events. August 4, 2008. Available at http://www.cms.gov/apps/media/fact_sheets.asp (follow August 04, 2008, hyperlink). Accessed January 23, 2011.
Freyer FJ. Hospital fined for wrong-site surgery. November 2, 2009. Available at http://news.providencejournal.com/breaking-news/2009/11/rhode-island-hospital-fined-15.html#.T0G53nJWofk. Accessed February 19, 2011.
- Understanding adverse events: human factors.Qual Health Care. 1995; 4: 80-89
- Incidence, patterns, and prevention of wrong-site surgery.Arch Surg. 2006; 141 (discussion 7–8): 353-357
U.S. Department of Health and Human Services. The National Practioner Data Bank. Available at http://www.npdb-hipdb.hrsa.gov/topNavigation/aboutUs.jsp. Accessed January 26, 2011.
- Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough.Ann Surg. 2003; 237: 844-851
- Adherence to surgical care improvement project measures and the association with postoperative infections.JAMA. 2010; 303: 2479-2485
- Nonpayment for performance? Medicare's new reimbursement rule.N Engl J Med. 2007; 357: 1573-1575
The Joint Commission. Sentinel event data: general information. October 18, 2011. Available at http://www.jointcommission.org/sentinel_event_data_general/. Accessed November 11, 2011.
Crane M. Wrong-site surgery occurs 40 times a week. June 29, 2011. Available at http://www.medscape.com/viewarticle/745581. Accessed October 30, 2011.
- Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complaints and non-complaints following adverse events.Qual Saf Health Care. 2006; 15: 17-22
- Wrong-site surgery.Hosp Health Netw. 2011; 85: 34-37
- Sanctions and recidivism: an evaluation of physician discipline by state medical boards.J Health Polit Policy Law. 2007; 32: 867-885
- The relationship between physicians' malpractice claims history and later claims: does the past predict the future?.JAMA. 1994; 272: 1421-1426
- Human factors engineering and patient safety.Qual Saf Health Care. 2002; 11: 352-354
- A human factors engineering paradigm for patient safety: designing to support the performance of the health care professional.Qual Saf Health Care. 2006; 15: i59-i65
The Joint Commission. Sentinel event data: root causes by event type. October 18, 2011. Available at http://www.jointcommission.org/Sentinel_Event_Statistics/. Accessed February 11, 2011.
The Joint Commission. Behaviors that undermine a culture of safety. July 08, 2008. Available at http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/. Accessed February 10, 2011.
- Patient safety in surgery.Ann Surg. 2006; 243 (discussion 32–5): 628-632
- Can aviation-based team training elicit sustainable behavioral change?.Arch Surg. 2009; 144: 1133-1137
- An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training.Am J Surg. 2008; 195: 546-553
- The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank.Health Aff (Millwood). 2005; (suppl Web exclusives):W5-240-9
The Joint Commission. National Patient Safety Goals. July 13, 2011. Available at http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed August 28, 2011.
- Serious Reportable Events in Health Care 2006 Update: a consensus report. National Quality Forum, Washington, DC2006
- Operating room briefings: working on the same page.Jt Comm J Qual Patient Saf. 2006; 32: 351-355
- Impact of preoperative briefings on operating room delays: a preliminary report.Arch Surg. 2008; 143: 1068-1072
- Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.Arch Surg. 2008; 143 (discussion 8): 12-17
- Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals.Health Aff (Millwood). 2010; 29: 1593-1599
- A multidisciplinary team approach to retained foreign objects.Jt Comm J Qual Patient Saf. 2009; 35: 123-132
- Surgery: safety culture, site-marking, checklists and teamwork.in: Wu A. Berman S. The value of close calls in patient safety: learning how to mitigate and avoid patient harm. Joint Commission Resources, Washington, DC2011