PA PSRS Patient Saf Advis 2007 Sep;4(3):72.
Query on Wrong-Site Surgery
Anesthesiology; Surgery
Expand All Collapse All

Query on Wrong-Site Surgery

PA-PSRS Patient Safety Advisory staff recently received a query from a reader in response to the article “Doing the ‘Right’ Things to Correct Wrong-Site Surgery” that appeared in the June 2007 issue. The reader questioned whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addressed the responsibility of physicians in preventing wrong-site surgery. Comments questioning responsibility in wrong-site surgery cases also appeared on the ABC Web site’s “Talk Back” section in response to a Good Morning America piece on wrong-site surgery that aired August 9, 2007;1  this television spot included commentary from John Clarke, MD, editor and clinical director, PA-PSRS. 

The emphasis of the PA-PSRS Patient Safety  Advisory has been on improving healthcare systems so that they can reliably deliver the right care to the right patient at the right time. Educating individual providers about what they can do to prevent or mitigate errors is useful, but not sufficient. It is our position that more improvement comes from improving a system than from improving the performance of individuals within an existing system. Nowhere is this more obvious than with “at-risk behavior.” Individuals should be educated about approaches that increase the risks of error and should be expected not to use them. However, facilities have the responsibility to monitor for at-risk behavior, counsel those who do it, provide encouragements and incentives for low-risk behavior, and provide barriers to keep at-risk behaviors from affecting patients. Examples abound, but one directly related to wrong-site surgery is that some hospitals will not load the scalpel blade into the handle until after the surgeon has done the time-out (see the aforementioned article in the June 2007 Advisory). Physicians, frequently not employees of the healthcare facility, should not be participating in at-risk behavior. However, physicians have a relationship with the facility predicated on explicitly stated behavior, and the facility has a responsibility to its patients to protect them against at-risk behavior by providers, including those on medical staff. We feel that arguments about who has more responsibility for patient safety misses the point that safety is the commitment of a system that includes both facilities and their medical staffs. 

The actions of the surgeons in the operating room (OR) were cited as the leading factor in wrong-site surgery in the article (under the section on “System Breakdowns”), and these actions were illustrated by several examples. When we compared 174 wrong-site surgery events with 253 wrong-site surgery near misses, we found that physician behavior in the operating room was the leading cause of wrong-site surgery events. Most of these events (92) involved the behavior of the surgeon in the operating room, with another 29 involving the behavior of the anesthesia provider. This detailed scientific study was presented to the American Surgical Association and was published in the September 2007 issue of the Annals of Surgery. Almost all of the recommendations involve actions by the surgeons.2 Publication of our analysis in this surgical journal was specifically chosen to reach and influence the thinking of practicing surgeons. PA-PSRS staff hope that facilities will take advantage of the information, which is available electronically (, to develop a strong working relationship between the OR physicians and support staff to commit to a safe patient experience in the OR. 


  1. Talk back [comment section online]. In: Surgical mishaps: wrong-site operations [television transcript online]. ABC News Good Morning America. 2007 Aug 9 [cited 2007 Aug 16]. Available from Internet:
  2. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg 2007 Sep;246(3):395-405.

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at

©2019 Pennsylvania Patient Safety Authority