Applying fault tree analysis to the prevention of wrong-site surgery.
Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.
This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.
Doctor uses 'pre-flight' checklist.
Bernhard B. The Orange County Register. April 19, 2006.
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.
Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.
Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.
Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.
COMMENTARYView all related resources...
Calland JF. AHRQ WebM&M [serial online]. January 2004.