AHRQ Patient Safety Network ► Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

AHRQ Patient Safety Network

Wrong-site surgery can occur despite use of Universal Protocol, owing to errors occurring before and after the Protocol's use.Am J Surg. 2015 Mar 21; [Epub ahead of print].

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

Paull DE, Mazzia LM, Neily J, et al. Am J Surg. 2015 Mar 21; [Epub ahead of print].

This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery events can occur despite adherence to the Universal Protocol, due to errors preceding and following the protocol's use. The authors suggest that additional processes initialized earlier and continuing later through the surgical process are required to fully prevent these events.

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