Toracocentesis del lado equivocado

1. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034.
2. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? Arch Surg. 2006;141(9):931-939.
3. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146(11):1235-1239.
4. Williams LC. Using magic to throw light on tricky healthcare systems: patient safety problem solving . Hum Factors Ergonomics Manufacturing Serv Industries. 2012;1(22):52-63.
5. Rittel HWJ, Melvin MW. Dilemmas in a general theory of planning. Policy Sciences. 1973:155-169.
6. Thomsen TW, DeLaPena J, Setnik GS. Videos in clinical medicine: thoracentesis. N Engl J Med. 2006;355(15):e16.
7. Daniels CE, Ryu JH. Improving the safety of thoracentesis. Curr Opin Pulm Med. 2011;17(4):232-236.
8. Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Process changes to increase compliance with the universal protocol for bedside procedures. Arch Intern Med. 2011;171(10):947-949.
9. Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg.2007;204(4):527-532.
10. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
11. Dror I. A novel approach to minimize error in the medical domain: cognitive neuroscientific insights into training. Med Teach. 2011;33(1):34-38.
12. Department of Veterans Affairs National Center for Patient Safety. Root cause analysis tools.http://www.patientsafety.va.gov. Accessed March 11, 2013.
13. Department of Veterans Affairs National Center for Patient Safety. Primary analysis and categorization glossary major actions.http://www.patientsafety.va.gov. Accessed March 11, 2013.
14. Ebel RL. Estimation of the reliability of ratings. Psychometrika. 1951;16:407-424.
15. Interrater reliability calculator.http://www.med-ed-online.org/rating/reliability.html. Accessed December 13, 2012.
16. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.
17. Wadhera RK, Parker SH, Burkhart HM, et al. Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? the impact of protocol-driven communication during cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2010;139(2):312-319.
18. The Joint Commission. Time out! conducting a final verification before surgery. Perspect Patient Safety.2009;9:1-11.
19. Directive VHA 2010-023. Ensuring correct surgery and invasive procedures.http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2922. Accessed March 11, 2013.
20. Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf. 2012;21(7):617-620.
21. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246(3):395-405.
22. Boodman SG. Effort to end surgeries on wrong patient or body part falters. Kaiser Health News website. June 20, 2011.http://www.kaiserhealthnews.org/stories/2011/june/21/wrong-site-surgery-errors.aspx. Accessed March 11, 2013.
23. de Vries EN, Smorenburg SM, Schlack WS, Gouma DJ, Boermeester MA. Implementation and effectiveness of a time-out procedure. Qual Saf Health Care. 2009;18:e1.
24. Stahel PF, Sabel AL, Victoroff MS, et al. 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(10):978-984.
25. Paige JT. Surgical team training: promoting high reliability with nontechnical skills. Surg Clin North Am. 2010;90(3):569-581.
26. Ofte SH, Hugdahl K. Right-left discrimination in male and female, young and old subjects. J Clin Exp Neuropsychol. 2002;24(1):82-92.
27. Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-1137.
28. Blouin AS, McDonagh KJ. Framework for patient safety, part 1: culture as an imperative. J Nurs Adm. 2011;41(10):397-400.
29. Warm JS, Parasuraman R, Matthews G. Vigilance requires hard mental work and is stressful. Hum Factors. 2008;50(3):433-441.
30. Aron DC, Headrick LA. Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Qual Saf Health Care. 2002;11(2):168-173.
31. Cook RI. Seeing is believing. Ann Surg. 2003;237(4):472-473.
32. Simons DJ, Chabris CF. Gorillas in our midst: sustained inattentional blindness for dynamic events. Perception. 1999;28(9):1059-1074.
33. Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10)(suppl):S109-S116.
34. Paull DE, Okuda Y, Nudell T, et al. Preventing wrong-site invasive procedures outside the operating room: a thoracentesis simulation case scenario. Simul Healthc. 2013;8(1):52-60.
35. Paull DE, Okuda Y, Nudell T, et al. Preventing wrong-site invasive procedures outside the operating room: a thoracentesis simulation case scenario. Simul Healthc. 2013;8(1):52-60.
36. Neily J, Mills PD, Paull DE, et al. Sharing lessons learned to prevent incorrect surgery. Am Surg. 2012;78(11):1276-1280.
37. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700