Transcript Evidence based Actions to Prevent Wrong Patient Site

Prevention of Wrong
Site Surgery
Evidence Based Actions
Lisa R. Spruce
DNP, RN, ACNS, ACNP, ANP, CNOR
Director, Evidence-Based Perioperative Practice
Association of periOperative Registered Nurses
Mary J. Ogg
MSN, RN, CNOR
Perioperative Nursing Specialist
Association of periOperative Registered Nurses
Objectives
1. Discuss the evidence presented for the
prevention of wrong site surgery.
2. Discuss best practices to minimize the
potential for wrong site surgery.
3. Identify the barriers to implementing best
practices for the prevention of wrong site
surgery.
The Wrong way to do a Time Out
Oregon Surgeon
Performs Wrong-Site
Surgery on FourYear-Old
Doctors
amputate
the wrong
leg
Wrong kidney
removed at
Medical Center in
New York City
Trail of errors led to 3
wrong brain surgeries.
Surgeons' ego at R.I.
hospital may have led
to carelessness.
Overview of the problem
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1,300-2,700 wrong site surgeries occur
annually in the U.S.
40-60 wrong site surgeries likely occur in the
U.S. each week
85% of wrong site surgeries analyzed had
inadequate planning
72% of wrong site surgeries analyzed had
defects in the "Time Out"
Source: Joint Commission Center for Transforming Healthcare
Cochrane Review-Background
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Wrong site surgery
Potentially disastrous error
Clinical interventions are needed to prevent
Risk factors
Variable
Complex
Organizational and professional strategies
Role in minimizing wrong site surgery
Cochrane review-Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Interventions for reducing
wrong-site surgery and invasive procedures. Cochrane Database Syst Rev. 2012;9:CD009404.
Cochrane Review
• Randomized controlled trail
- Difficult to compare the use of a pre-op checklist
against a control group
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Controlled before-after studies (CBA)
Case-controlled studies
Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Interventions for reducing wrong-site surgery and invasive procedures. Cochrane
Database Syst Rev. 2012;9:CD009404.
Steelman- Top Patient Safety Issue
Anonymous electronic survey of AORN member
database
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68.6 % identified preventing wrong site,
procedure/patient surgery as one of the five highest
priorities
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Identified more than any other issue in all five regions
of the US.
Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified
by perioperative nurses. AORN J. 2013;97(4):402-418.
Birnbach
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Discussion about a framework for
patient safety.
7 principles for patient safety
discussed.
Bohmer
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Study to evaluate peri-op safety standards and the
quality of interprofessional cooperation before and
after the introduction of a safety checklist from staff
members’ point of view.
Methods: Surveyed employees 3 months after the
introduction of an adapted surgical safety check list.
Results: From the staff perspective, safety factors can
be handled significantly better and with greater
awareness by implementing a safety checklist.
Bohmer, A. B., F. Wappler, T. Tinschmann, P. Kindermann, D. Rixen, M. Bellendir, et al. "The
implementation of a perioperative checklist increases patients’ perioperative safety and staff
satisfaction."ACTA ANAESTHESIOLOGICA SCANDINAVICA. 56. (2012): 332-338. Print.
Braff
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Literature review that explored the role of documents
and documentation in communication failure among
HCPs across the peri-op, intra-op, and post-op areas.
Results: highlighted that documentation such as
surgery notes, anesthesia records, and nurses peri-op
notes that are deficient contribute to the development
of communication failures leading to WSS.
Conclusion: Effective communication is vital to the
delivery of safe patient care.
Braff, S, E Manias, and R Riley. "The role of documents and documentation in communication failure across the perioperative pathway. A literature
review."International Journal of Nursing Studies. 48. (2011): 1024-1038. Print.
Clark
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Pennsylvania Patient Safety Authority study to identify the barriers
to implementation and strategies for successful implementation of
the 21 PPSA recommendations for preventing WSS.
Surveyed 417 facilities (160 hospitals and 257 ambulatory facilities).
Results:
1. Physician behavior-surgeon intimidation, resistance, non-compliance, lack
of accountability, acceptance, commitment, engagement, cooperation from
surgeon officers, lack of percieived value, surgeons unavailable, surgeons
overriding protocols.
2. Difficulty with accurate pre-op information.
3. Barriers to 2nd verification of intra-op spinal level
Clark, cont’d
4. Need to change policy
5. Need to monitor compliance
6. Time pressures
7. Educate personnel
8. Inability to see site markings
9. General communication problems
10. Need to change culture
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Clark, J. "What Keeps Facilities from Implementing Best Practices to Prevent Wrong-Site Surgery? Barriers and Strategies for Overcoming
Them."Pennsylvania Patient Safety Advisory. 9.Suppl 1 (2012): 1-16. Print.
Gibbs
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Expert opinion
Discusses TJC Targeted Solutions Toolkit
Provides a step by step process to measure
performance.
TJC project showed that in 39% of WSS cases
errors usually involved inadequate information
about the patient and scheduling confusion.
Gibbs, V. "Thinking in three's: Changing surgical patient safety practices in the complex modern operating room." World Journal of Gastroenterology.
18.46 (2012): 6712-6719. Print.
Hu
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Discussion of the importance of video-based
observations on the study of OR safety and
human factors.
Case study presented, a video observation of
OR team dealing with an equipment issue.
Team maintained situational awareness,
circulator led the team, directed them and they
cooperated; allowed for a quick recovery and
prevention of a catastrophic event.
Hu, Y. Y., et al. "Protecting Patients from an Unsafe System: The Etiology and Recovery of Intraoperative Deviations in Care." Annals of
Surgery 256.2 (2012): 203-10. .
Hyman
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Children’s Hospital of Colorado began placing patient
pictures into the medical record to determine if it would
decrease unintended patient orders and increase
patient verification.
Before initiative: 24% of reported errors were due to
placement of orders in the incorrect chart.
After the initiative: 15 months after the initiative there
was no unintended care and no patient’s with pictures
received wrong orders.
Strategy could be used to improve patient verification
to prevent WSS.
Hyman, D., et al. "The use of Patient Pictures and Verification Screens to Reduce Computerized Provider
Order Entry Errors." Pediatrics 130.1 (2012): e211-9.
James
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Study by the American Board of Orthopedic Surgery.
Reported the incidence and nature of WSS reported by board
candidates between 1999-2010.
Results: 76 WSS-spine most common, most near misses,singlelevel lumbar laminectomy –most common procedure.
Did not improve after implementation of UP-mandated in 2008.
Conclusion: Adding additional layers of precautions and improving
communication among the healthcare team and shared
responsibility among team members is needed. More effective of
discerning the correct spine level are needed.
James, M. A., et al. "The Occurrence of Wrong-Site Surgery Self-Reported by Candidates for Certification by the American Board
of Orthopaedic Surgery." The Journal of bone and joint surgery.American volume 94.1 (2012): e2(1-12).
Kalapurakal
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Instituted a voluntary error reporting system to record errors.
Analyzed the clinical impact and guided the implementation
of targeted QA measures.
In response to these errors, a novel initiative involving the
use of check lists and timeouts for all staff was implemented.
Results: the voluntary error database recorded a total of 356
errors related to wrong treatment, wrong site, wrong patient,
and wrong dose.
The program instituted checklists, time outs, and monitored
staff compliance and successfully eliminated the errors.
Kalapurakal, J. A., et al. "A Comprehensive Quality Assurance Program for Personnel and Procedures in
Radiation Oncology: Value of Voluntary Error Reporting and Checklists." International journal of radiation
oncology, biology, physics 86.2 (2013): 241-8
Lee
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Study looked at the use of a surgical safety checklist in 3 hospitals.
Looked at WSS after implementation and 4 years later.
Team members were recorded and process discrepancies reviewed.
Surgeon attitudes were analyzed with a survey.
Results: over the 4 years, completion on the checklist improved
from 87%-98% and discrepancies increased from 7.7% to 9.3%. The
most common discrepancy was the absence of the surgeon during
the time out process.
Only 86% of surgeons believed that the timeout process was
valuable in reducing WSS.
Continues to be surgeon resistance.
Lee, A. J., et al. "The Time Out Procedure: Have we Changed our Practice?" The New Zealand medical
journal 125.1362 (2012): 26-35.
Lee
Study looked at the fact that WSS has not improved in spine
surgery in spite of prevention programs in place by the:
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Canadian Orthopedic Association
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WSS occurred because of communication barriers.
American Academy of Orthopedic Surgeons
North American Spine Society
UP by TJC
Reports have shown that the highest incidence of WSS
occurred in orthopedic procedures, 5-8% involved the
spine.
Lee, S. H., et al. "Patient Safety in Spine Surgery: Regarding the Wrong-Site Surgery." Asian spine
journal 7.1 (2013): 63-71.
Liou
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Literature review of WSS in head and neck surgery.
Results: 0.3-4.5% of all WSS are otolaryngology procedures.
Particular issues are inverted imaging and ambiguity on site
marking.
Conclusions: standardizing protocols to confirm imaging
accuracy, a specialty or procedure specific check list and a
standardized alternative to site marking when marking is
impractical and other innovative ideas.
Liou, T. N., and B. Nussenbaum. "Wrong Site Surgery in Otolaryngology-Head and Neck Surgery." The
Laryngoscope (2013) .
Longo
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Errors of level in spine surgery-an evidence based systematic
review.
Looked at incidence and prevalence of WSS and prevention
strategies.
12 studies reviewed.
10 studies looked at lumbar.
2 looked at lumbar, thoracic, or c-spine.
Higher frequency of wrong level surgery in lumbar
procedures than in cervical procedures.
Studies demonstrated that current site verification protocols
did not prevent about 1/3 of cases.
Further prevention strategies need to be developed to reduce
the risk of WSS in spinal procedures.
Longo, U. G., et al. "Errors of Level in Spinal Surgery: An Evidence-Based Systematic Review." The Journal
of bone and joint surgery.British volume 94.11 (2012): 1546-50.
Mainthia -Electronic whiteboard
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Background
Evidence that time out is effective
Low compliance with completion of checklist
Prospective observational study
Interactive electronic checklist system (iECS)
Pre-intervention observations
49.7% of core elements
Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases
surgical team compliance with pre-incision safety practices. Surgery. 2012;151(5):660-666.
Mainthia -Interactive electronic
checklist
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Visible to entire team
Referenced during the pre-incision time out
Required time out steps- red
Each item is announced and checked by circulator
when completed
Completed time out steps turn green
Completed checklist – “time out complete”
Completion time- > 1 minute ( average 35 seconds)
Mainthia-Electronic whiteboard
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Post intervention observations-1 month
81.6% of core elements
Post intervention observations-9 months
85.6% of core elements
36.1% increase
Statistically significant increase in time out procedural
compliance
Improving patient outcomes
Reducing preventable complications and death
Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases
surgical team compliance with pre-incision safety practices. Surgery. 2012;151(5):660-666.
Papaconstantinou -Implementation
of a surgical safety checklist
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Pre/post study design
Evaluated surgical team perspectives
Before and after implementation of a WHO adapted checklist
Checklist developed by multidisciplinary team (eg, surgery,
nursing)
Education campaign
Mandatory, online module
Educational video showing the checklist process
Visuals in the OR suite
FAQs
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a surgical
safety checklist: Impact on surgical team perspectives. Oschner J.2013;13: 299-309.
Papaconstantinou -Implementation
of a surgical safety checklist
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Survey of provider perceptions and checklist elements
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1 month before checklist implementation
1 year after checklist implementation
Survey themes and topics
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Surgical team communication
Patient safety
Patient care & quality measures
Teamwork
Participants
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Surgeons-41%
Nurses-35%
Anesthesia providers-24%
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a surgical
safety checklist: Impact on surgical team perspectives. Oschner J.2013;13: 299-309
Papaconstantinou -Implementation
of a surgical safety checklist
Survey results
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Improvements
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awareness of patient safety
communication
quality of care
perception of the value and participation in the time out process
surgical team communications
Negatives
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OR efficiency
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a surgical
safety checklist: Impact on surgical team perspectives. Oschner J.2013;13: 299-309
Thakkar -Visibility of site marking
Background
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Very important component of the time out is the visibility of the
surgical site marking
Prospective randomized controlled trial
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Quantitatively and qualitatively evaluated the visibility of the surgical
site markings after using 2 skin prep solutions
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Black permanent marker used to mark the patients skin
Randomly assigned to chlorhexidine or iodine based skin prep
Digital photographs before and after skin prep application
Quantitative and qualitative analysis by 10 orthopedic surgeons
Thakkar SC, Mears SC. Visibility of surgical site marking: A prospective randomized trial of two skin
preparation solutions. J Bone Joint Surg Am. 2012;94(2):97-102.
Thakkar -Visibility of site marking
Results
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Chlorhexidine-based skin preparation solution erases
surgical markings more frequently than iodine-based
skin preparations.
Additional research is needed to find a skin prep that
has maximal effect to prevent infections and does not
erase site markings.
Chosen marker may be more susceptible to the effects
of chlorhexidine.
Thakkar SC, Mears SC. Visibility of surgical site marking: A prospective randomized trial of two skin
preparation solutions. J Bone Joint Surg Am. 2012;94(2):97-102.
Case study-wrong knee surgery
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Patient scheduled for a left ACL repair
Surgeon operated on right knee
Site marking not visible
Surgeon assumed that prep had washed off
the markings
Vachhan-Neurosurgical wrong-site surgeries
before & after implementation of Universal
protocol
Background
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Neurosurgery wrong site surgeries
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2-3 per 10,000 craniotomies
6-14 per 10, 000 spine surgeries
Method
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Retrospective review
Number of neurosurgical wrong site surgeries at a Midwestern
university hospital from 1999-2011
Vachhani JA, Klopfenstein JD. Incidence of neurosurgical wrong-site surgery before and after
implementation of the universal protocol. Neurosurgery. 2013;72(4):590-5; discussion 595.
Vachhan-Neurosurgical wrong-site surgeries
before & after implementation of Universal
protocol
Results: Number of neurosurgical wrong site
surgeries(WSS)
• Before implementation of universal protocol
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No event-7274
WSS-12 ( wrong level spine surgeries)
After implementation of universal protocol
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No event- 15,454
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Culture shift in OR to a team based approach to prevent WSS
WSS-3 ( 1 wrong side craniotomy, 2 wrong level spine surgeries)
Statistically significant
Switch to electronic picture archiving of patient images simplifying
intraoperative localization
Oszvald- Team time out and
surgical safety-neurosurgical
patients
Background
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Use of a perioperative checklist for elective neurosurgical procedures
Retrospective review
perioperative checklist time period (2007-2010)
advance perioperative checklist that included patient identification,
preoperative assessments, team time-out, and post-op treatment time
period (2011-2012)
Results
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Perioperative check list period- 2 WSS (1 elective spine & 1 emergency burr
hole)
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Advanced perioperative checklist- 0 WSS
Oszvald A, Vatter H, Byhahn C, Seifert V, Guresir E. "Team time-out" and surgical safetyexperiences in 12,390 neurosurgical patients. Neurosurg Focus. 2012;33(5):E6.
Yoon -Using “near misses” analysis
to prevent wrong-site surgery
Pre-post intervention study to reduce number of near-miss events at an
academic, orthopedic surgery specialty institution
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Incorrectly booked surgeries
Incorrectly performed time-out
Intervention
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Education for the surgeon & staff about the importance of accurate surgical
scheduling
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Counseling for team member who performed time-out improperly
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Results
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Decreased incorrectly booked cases from 0.75% to 0.41% ( p=.0139)
Decreased improperly performed time-outs from 18.7% to 5.9% (p<.0001)
Education regarding the importance of decreasing wrong site surgeries
Yoon RS, Alaia MJ, Hutzler LH, Bosco JA. Using “near misses” analysis to prevent wrong-site surgery. J Healthc Qual.2013
Case study-outpatient surgery
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Incorrect operation on a hand
Scheduled for release of trigger finger- left ring finger
Left carpal tunnel procedure performed
Surgeon
Several procedures-major and minor
Served as translator for the patient in pre-op
Pre-op nurse marked the wrist
Performed a carpal tunnel on another patient
Case moved to another room to accommodate surgery schedule
Different OR crew
Left OR suite to do a consultation
Case study-outpatient surgery
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Surgeon
Counseled an upset, previous patient
Anxiety producing
No tourniquet-circulator left room
Patient prepped-wiped off site marking
Communicated in Spanish to the patient
Circulator thought it was the time out
Team was relieved in the middle of the procedure
Realized mistake when dictating
Discussed with patient & performed correct procedure
Case study-outpatient surgery
Breakdown in skill-based behavior, rule-based
behavior, & knowledge-based behavior
- Distraction
- Personnel change
- Inpatient consult
- Previous patient’s needs
- Patient's language needs
- Familiarity with the task at hand
Papaconstantinou- Barriers to
implementation of the checklist
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Redundancy
Duplication of items in existing checklists
Poor communication between surgical team members
Negative perception of efficiency
Time spent completing the checklist
Lack of understanding & commitment to the process
Buy-in of all surgical care providers
Ambiguity
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a surgical
safety checklist: Impact on surgical team perspectives. Oschner J.2013;13: 299-309.
Papaconstantinou-Effective
implementation strategies of a checklist
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Explaining why & showing how
Active leadership
Deliberate enrollment
Extensive discussion & training
Piloting
Multidisciplinary communication
Real-time coaching
Ongoing feedback
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a
surgical safety checklist: Impact on surgical team perspectives. Oschner J.2013;13: 299-309
Rydrych-Successful time out
process
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5.
6.
Details matter
Focus on implementation as much as process
development
Go with the (work) flow ….& acknowledge our
“humanness”
Focus on key elements
Align activities with other initiatives
Persistence is key
Rydrych D, Apold J, Harder K. Preventing wrong-site surgery in Minnesota: A 5year journey. Patient Saf Qual Healthc. 2012;9(6):24-34
Rydrych- #1 Details matter
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Perform a robust time-out
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Develop clear, detailed policies & procedures
Do not rely on memory or perform in a rote
manner
Follow all steps in the policies & procedures
Actively participate in the time out with all
members of the procedure team
Rydrych D, Apold J, Harder K. Preventing wrong-site surgery in Minnesota: A 5-year
journey. Patient Saf Qual Healthc. 2012;9(6):24-34
Rydrych- #2 Focus on
implementation as much as process
development
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Plan the implementation
Devote sufficient resources
Engage surgeon champion
Educate all team members
Support & coach staff
Communicate with key stakeholders
Monitor ongoing compliance
Provide ongoing training and refresher training
Involve process leaders to identify strategies with front-line
staff to overcome roadblocks
Rydrych-Acknowledge our
“Humanness”
Regardless of our training or intelligence
- Humans forget things
- Humans make mistakes
- Humans downplay risks
- Humans go on auto-pilot
Overconfidence
- Errors are due to other’s insufficient skill or intelligence
Automated behaviors
- Example-driving the same route to work every day and when
you arrive at work not remembering the details of the drive
Rydrych- # 3 Go with the (work) flow
….& acknowledge our “humanness
Be aware of, account for, and develop strategies.
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Confirmation bias
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Discounting info that disagrees with preconceived ideas
(eg, site marking is different from informed consent)
Risk perception
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Assuming errors or mistakes will happen to someone
else
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Overconfidence
Automated behaviors
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Going through the motions of a time out without paying
attention to the steps
Rydrych- # 4 Focus on key
elements
Minnesota Time Out process
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Surgeon initiates the time out
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Anesthesia verbally reads the patient's name &
shorthand version of the procedure
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Scrub verbalizes the site marking and the set up for
procedure
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Surgeon states patient's name and complete
procedure from memory
Team ceases all activity
Circulator verbally reads the patient's name,
procedure, & procedure from the informed consent
Rydrych- #5 Align activities with
other initiatives
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Integrate into current efforts (eg, WHO
checklist, Joint Commission’s universal
protocol)
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May facilitate buy-in from surgeons and
administration
Rydrych- #6 Persistence is key
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Adaptive change does not happen quickly
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Executive & clinical leaders
Time out process is an evolving practice
Support of staff, physicians, & leaders is needed for long
term change
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Communicate expectations to physicians & staff
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Keeps the circulating nurse from playing the policeman trying to enforce
policies and procedures with surgeons and staff who do not want to modify
their practice
Provide resources
Be a visible support
Recognize individual & organizational successes
Birnbach -Evidence-based Actions
to Prevent WSS
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Leadership commitment.
Everyone is responsible.
Empower governing bodies to create and enforce
safety policies.
Eliminate preventable harm.
Establish a universal, uniform approach for safety
management.
Mandate reporting of safety issues, errors, and
near misses.
Cultivate learning as part of the organizational
mentality.
Evidence-based Actions to Prevent
WSS
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Develop policies where medical staff is educated,
performance monitored, and feedback provided.
Leadership promotes patient safety and encourages medical
staff to voluntarily participate in safety initiatives.
Multiple procedures on the same patient should have
individual time outs and should be done separately after
changing the position.
Eliminate the hierarchy. All must feel free to speak up when a
patient safety issue is noticed.
Emphasize the team approach and team responsibility,
eliminate name-blame-shame.
Steelman-Recommendations
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Improve accuracy of scheduling information
(eg, checklist for scheduling surgery)
Verify necessary documentation and site
marking in pre-op area
Enforce time out procedure
Avoid workarounds
Engage all team members with no deviations
Steelman VM, Graling PR. Top 10 patient safety issues: What more can we do? AORN J.
2013;97(6):679-98, quiz 699-701.
Pennsylvania Patient Safety
Authority Resources
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OR scheduling form
Observational monitoring tool
Compliance monitoring tool
Wrong-site surgery error analysis
Self-assessment checklist for program
elements
Independent verification
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/home.aspx
Successful Time Out Process
Summary
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Checklists
Education
Active team participation
Visible site marking
Administrative support
References
Birnbach DJ, Rosen LF, Williams L, Fitzpatrick M, Lubarsky DA, Menna JD. A framework for patient safety: A defense nuclear industry-based high-reliability model. Jt Comm J Qual Patient Saf. 2013;39(5):233-240.
Bohmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients' perioperative safety and
staff saLee SH, Kim JS, Jeong YC, Kwak DK, Chun JH, Lee HM. Patient safety in spine surgery: Regarding the wrong-site
surgery. Asian Spine J. 2013;7(1):63-71.
tisfaction. Acta Anaesthesiol Scand. 2012;56(3):332-338.
Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A
literature review. Int J Nurs Stud. 2011;48(8):1024-1038.
Clarke JR. What keeps facilities from implementing best practices to prevent wrong-site surgery? barriers and strategies for overcoming
them. PA Patient Saf Advis. 2012;9((Suppl 1)):1-15.
Gibbs VC. Thinking in three's: Changing surgical patient safety practices in the complex modern operating room. World J Gastroenterol.
2012;18(46):6712-6719.
Hu YY, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: The etiology and recovery of intraoperative deviations in
care. Ann Surg. 2012;256(2):203-210.
Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures and verification screens to reduce computerized provider order
entry errors. Pediatrics. 2012;130(1):e211-9.
James MA, Seiler JG,3rd, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification
by the american board of orthopaedic surgery. J Bone Joint Surg Am. 2012;94(1):e2(1-12).
Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and procedures in radiation
oncology: Value of voluntary error reporting and checklists. Int J Radiat Oncol Biol Phys. 2013;86(2):241-248.
References
Longo UG, Loppini M, Romeo G, Maffulli N, Denaro V. Errors of level in spinal surgery: An evidence-based systematic review. J Bone Joint
Surg Br. 2012;94(11):1546-1550.
Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Interventions for reducing wrong-site surgery and invasive procedures.
Cochrane Database Syst Rev. 2012;9:CD009404.
Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with
pre-incision safety practices. Surgery. 2012;151(5):660-666.
Oszvald A, Vatter H, Byhahn C, Seifert V, Guresir E. "Team time-out" and surgical safety-experiences in 12,390 neurosurgical patients.
Neurosurg Focus. 2012;33(5):E6.
Papaconstantinou HT, ChanHee J, Reznik SI, Smythe Wr, Wehbe-Janek H. Implementation of a surgical safety checklist: Impact on surgical
team perspectives. Oschner J.2013;13: 299-309.
Rydrych D, Apold J, Harder K. Preventing wrong-site surgery in Minnesota: A 5-year journey. Patient Saf Qual Healthc. 2012;9(6):24-34.
Steelman VM, Graling PR. Top 10 patient safety issues: What more can we do? AORN J.2013;97(6):679-98, quiz 699-701.
Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4):402-418.
Thakkar SC, Mears SC. Visibility of surgical site marking: A prospective randomized trial of two skin preparation solutions. J Bone Joint Surg
Am. 2012;94(2):97-102.
Vachhani JA, Klopfenstein JD. Incidence of neurosurgical wrong-site surgery before and after implementation of the universal protocol.
Neurosurgery. 2013;72(4):590-5; discussion 595.
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