Never events, oubli de corps étrangers, mauvais patient, mauvais site, mauvaise procédure

Gunnar W., Soncrant C., Lynn M.^, Neily J.,Tesema Y., Nylander W. The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration, Journal of Patient Safety: December 2020 - Volume 16 - Issue 4 - p 255-258 

Geraghty, A., Ferguson, L., McIlhenny, C., & Bowie, P. (2020). Incidence of Wrong-Site Surgery List Errors for a 2-year period in a single national health service board. Journal of Patient Safety, 16(1), 79.

Omar, I., Singhal, R., Wilson, M., Parmar, C., Khan, O., & Mahawar, K. (2021). Common general surgical never events: analysis of NHS England never event data. International Journal for Quality in Health Care, 33(1), mzab045.

Vacheron, C. H., Acker, A., Autran, M., Fuz, F., Piriou, V., Friggeri, A., & Theissen, A. (2023). Insurance Claims for Wrong-Side, Wrong-Organ, Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10 Years. Journal of Patient Safety, 19(1), e13-e17.

Martin-Fumadó C., Benet-Travé J., & Arimany-Manso J. (2023). Wrong-Site Surgery in Spain and Professional Liability Claims. Journal of Patient Safety, 19(5), e63.

Gawande A., Studdert D., Orav J., Brennan T., Zinner M., Risk factors for retained instruments and sponges after surgery, N Engl J Med 2003;348:229-35.

Gibbs V., Mc Grath M., Russell T. The prevention of retained foreign bodies after surgery. Bulletin of the American College of Surgeons. 2005;90(10):12

Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353–357.

Sieden S ., Barach P., Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events, Are They Preventable?, Arch Surg. 2006;141:931-939

Clarke J., Johnston J., Finley E. Getting surgery right, Ann Surg, 2007, 246, 3:395-405

Simon J., Ngo Y. Khan S., Strogatz D., Surgical confusions in Ophtalmology,  Arch.Ophtalmology, 2007, 125 (11) 1515-1522

Stanton M., Tong Ngok S., Liguori G., Edmonds , A New Approach to Preanesthetic Site Verification After 2 Cases of Wrong Site Peripheral Nerve Blocks, Reg Anesth Pain Med 2008;33:174-177

Egorova, N., Moskowitz, A., Gelijns, A., Weinberg, A., Curty, J., Rabin-FAstman, B., Kaplan, H., Cooper, M., Fowler, D., Emond, J., Greco, G., Managing the prevention of retained surgical instruments: what is the value of counting, Ann Surg, 2008, 247, 1° 13-18

Greenberg C., Diaz-Flores R. Lipsitz S., Regenbogen S., Mulholland L., Mearn F, et al. Bar-coding surgical sponges to improve safety: a randomized controlled trial. Annals of surgery. 2008;247(4):612.

Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era Analysis of a Prospective Database of Physician Self-reported Occurrences Archives of Surgery 2010;145(10):978-984

Cohen S., Hayek S., Datta S., Bajwa Z., Larkin T., Griffiteh S., Hobelmann G., Christo P., Whide R., Incidence of Root cause analysis of Wrong-site pain management procedures, Anesthesiology, 2010, 112 :711-8

DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site surgery: a systematic review. Spine. 2010;35(suppl 9):S28-S36

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Steelman, Cullen, Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis, AORN Journal Volume 94, Issue 2 , Pages 132-141, August 2011

Neily J, Mills PD, Eldridge N, Carney BT, Pfeffer D, Turner JR, Young-Xu Y, Gunnar W, Bagian JP. Incorrect surgical procedures within and outside of the operating room: a follow-up report, Arch Surg. 2011 Nov;146(11):1235-9

Rydrych D., Apold J., Harder K. Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey, PSQH Patient Safety & Quality Healthcare, November-December, @journal

Makary M. Methsun W., Ibrahim A., Westr MD. Pronovost P. Malpractice Study: Surgical 'Never Events' Occur at Least 4,000 Times Per Year in U.S., Surgery, Publication on line,  21 december 2012

Adelman J. Kalkut  G.,  Schechter C.,  Weiss J., Berger M.,  Reissman S., Cohen H.  Lorenzen S., Burack D., Southern W , Understanding and preventing wrong-patient electronic orders: a randomized controlled trial J Am Med Inform Assoc doi:10.1136/amiajnl-2012-001055

Henneman, Philip L., Jenna L. Marquard, Donald L. Fisher, Justin Bleil, Brendan Walsh, Justin P. Henneman, Fidela S. Blank, Ann Marie Higgins, Brian H. Nathanson, et Elizabeth A. Henneman. « Bar-code Verification ». JONA: The Journal of Nursing Administration 42, no 12 (décembre 2012): 562 566.

Pikkel, Dvora, Adi Sharabi-Nov, et Joseph Pikkel. « It is the left eye, right? » Risk Management and Healthcare Policy 7 (8 avril 2014): 77 80.

Miller KE, Mims M, Paull DE, et et al.  Wrong-side thoracentesis: Lessons learned from root cause analysis . JAMA Surgery, 11 juin 2014.

Hempel S, Maggard-Gibbons M, Nguyen DK, et et al.  Wrong-site surgery, retained surgical items, and surgical fires : A systematic review of surgical never events . JAMA Surgery, 10 juin 2015.

Lima D., Sacks M., Blackman W., Benn J., Surgical Swab Counting: A Sociotechnical Analysis from the Perspective of the Scrub Nurse, submitted BMJQS, July 2012

Thiels, C., Mohan Lal T., Nienow J., Pasupathy K., Blocker R., Aho J., Morgenthaler T., Cima R., Hallbeck S., Bingener J.  Surgical Never Events and Contributing Human Factors. Surgery 158, no 2 (1 août 2015): 515 21.

Steelman, V., Schaapveld A., Perkhounkova Y., Storm H., Mathias M..  The Hidden Costs of Reconciling Surgical Sponge Counts AORN Journal 102, no 5 (1 novembre 2015): 498 506. 

Jones, S., Ashton C., Kiehne L., Gigliotti E., Bell-Gordon C., Disbot M., Masud F., Shirkey B., N.Wray. Reductions in Sepsis Mortality and Costs After Design and Implementation of a Nurse-Based Early Recognition and Response Program Joint Commission Journal on Quality and Patient Safety 41, no 11 (1 novembre 2015).

Fencl, J. Guideline Implementation: Prevention of Retained Surgical Items. AORN Journal 104, n^o 1 (1 juillet 2016): 37‑48.

Inaba K., Okoye O., Aksoy H., Skiada D., Ault G., Sener S., Lam L., Benjamin E., Demetriades, The Role of Radio Frequency Detection System Embedded Surgical Sponges in Preventing Retained Surgical Sponges: A Prospective Evaluation in Patients Undergoing Emergency Surgery  Annals of Surgery October 2016, 264, 4 : 599-604