Pa Patient Saf Advis 2008 Mar;5(1):31-2.
Quarterly Update on the Preventing Wrong-Site Surgery Project
Anesthesiology; Surgery
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Quarterly Update on the Preventing Wrong-Site Surgery Project

The published PA-PSRS data on wrong-site surgery events has been revised as a result of discovering events that were neither classified as wrong-site events, even though they were, nor classified as having occurred in an operating room or ambulatory surgical facility, even though they did. These data supersede all previous PA-PSRS data on wrong-site surgery events. A revised graph of the cumulative number of reports of wrong-site surgery events has been extended through the fourth quarter of 2007 and replaces the previously published graph on the Pennsylvania Patient Safety Authority’s Web site.* A graph of the number of reports by quarter, also based on the revised data (see Figure), has been added. Please note that the current definition of wrong-site surgery follows the National Quality Forum definition and includes punctures of the skin for the injection of local or regional anesthesia preparatory to the scheduled procedure.1 An improved search strategy will be used for all future searches for wrong-site surgery reports. Although there has been a slight drop in the number of reports of wrong-site surgery events, PA-PSRS clinical analysts are not impressed that there has been an improvement in wrong-site surgery incidence in Pennsylvania.

Figure. PA-PSRS Wrong-Site Surgery Reports by Quarter

Figure. PA-PSRS Wrong-Site Surgery Reports by Quarter

Detailed wrong-site surgery reports are being submitted by cooperating facilities in follow-up to reports of near-miss and actual wrong-site events. By comparing the processes that were and were not significantly associated with trapping the error before harm occurred, the clinical analysts can better understand which processes are associated with successfully catching these rare events. As of February 25, 2008, the analysts have received the results of 34 in-depth queries about near-miss events and 14 about actual wrong-site surgery events from 33 cooperating facilities. The compliance rate with requests for detailed information within 30 days of the event has been more than 63%. Currently, six elements of a prevention program for wrong-site surgery are more commonly present when errors were trapped than when the errors advanced to wrong-site surgery (see Table). The most persistent element, having also been the most apparent in the first quarterly review that published in the December 2007 Advisory,* is the response of the surgeon to concerns that were raised by others. Surgeons participating in preoperative verification and reconciliation processes also support the concept that involvement of the surgeons in any program to prevent wrong-site surgery is crucial.

Table. Current Preliminary Associations between Elements of a Prevention Program for Wrong-Site Surgery and Success in Trapping Wrong-Site Errors before Harm Occurred


Near Misses

Wrong-Site Surgeries

Significance (P Less Than)

Identification involved wristband and chart




Mark visible during time out




Surgeon did a preoperative verification




Surgeon reconciled discrepancies in documents




Someone raised a concern




Surgeon responded to the concern raised





Note that other elements that appeared to be associated with error trapping in the initial preliminary assessment of detailed wrong-site surgery reports (see the December 2007 Advisory) are not currently associated in this analysis of the expanded data set. The inverse association with scheduling errors disappeared, as did direct associations with the use of checklists and the use of time outs after repositioning the patient.

In a separate inquiry, analysts examined the subsequent experiences of facilities that indicated in a 2007 survey** that changes were initiated as a result of the June 2007 Advisory article “Doing the ‘Right’ Things to Correct Wrong-Site Surgery.” Of 180 facilities that returned survey responses, 62 indicated that changes were implemented as a result of this particular article. During the six months before the article published, this group of facilities had reported six wrong-site surgery events, in contrast to two wrong-site surgery reports among the 118 facilities that did not indicate a change as a result of this article. During the six months after the article, the numbers were exactly the same: six more wrong-site surgery reports among the facilities that had made a change and two more wrong-site surgery reports among those that had not. However, no facility in either response group reported a wrong-site surgery error in 2007 both before and after the article. The new reports that were submitted after the article was published were all from different facilities than the reports preceding the article.

The Health Care Improvement Foundation (HCIF) Partnership for Patient Care is implementing a Wrong-site Surgery Prevention Program for surgical facilities in the greater Philadelphia area. Part of the program is to correlate elements on the Pennsylvania Patient Safety Authority’s “Self-Assessment Checklist for Program Elements Associated with Preventing Wrong-Site Surgery” with reports of wrong-site surgery events. A more user-friendly version of the checklist is now available on the Pennsylvania Patient Safety Authority’s Web site in the toolkit “Preventing Wrong-Site Surgery.”* By comparing facilities that do and do not have each element on the checklist with existing reports of wrong-site surgery events, the analysts may gain some insight into which suggested elements are actually associated with fewer events.

All Pennsylvania facilities that conduct surgical procedures have been invited to join this voluntary endeavor. The Authority also invites any other state collecting wrong-site surgery events to use the same checklist to replicate the study. Requests for further information can be obtained by contacting the Authority (; please address requests to John Clarke, MD, Clinical Director, Pennsylvania Patient Safety Authority).

PA-PSRS analysts will continue to track and analyze all reports of wrong-site surgery events and near misses. In the meantime, hospitals and ambulatory surgical facilities are encouraged to assess their program for preventing wrong-site surgery using the checklist on the Authority’s Web site. Please consider sharing these assessments and the success or failure of any efforts to improve wrong site surgery programs. Facilities outside Pennsylvania are also welcome to share this information.

* The Pennsylvania Patient Safety Authority has posted an online toolkit of articles, educational resources, and data snapshots pertaining to wrong-site surgery.

** This survey refers to the annual online user survey conducted among Patient Safety Officers in Pennsylvania.


  1. National Quality Forum. Serious reportable events in healthcare—2006 update. Washington DC: National Quality Forum; 2007.

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