Pa Patient Saf Advis 2010 Jun;7(2):65-8.
Quarterly Update on the Preventing Wrong-Site Surgery Project
Anesthesiology; Nursing; Surgery
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Quarterly Update on the Preventing Wrong-Site Surgery Project

Some have changed. Most have not. Same approach. Same upshot.

The number of wrong-site surgeries in Pennsylvania increased during the first quarter of 2010 (see Figure 1), despite the availability of evidence-based best practices.* As usual, this quarterly article has been updated to include any belated additions and corrections from previous reporting quarters. Once again, wrong-site anesthetic blocks were the most commonly reported (three), with two reports of wrong vertebral level and two reports of wrong-site procedures on the breast.

Figure 1. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Quarter

Figure 1. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Quarter


Is elimination of wrong-site surgery possible? Anecdotal evidence suggests facilities can minimize their risk for this surgical “never event.” Perhaps, others can benefit from these facility experiences.

* The Pennsylvania Patient Safety Authority has a Web page devoted to educational tools for preventing wrong-site surgery. Its resources include all of the Authority’s publications on the subject, including self-assessment tools, sample forms and checklists, educational posters and videos, illustrative figures and tables, and patient education brochures, as well as links to information from other Web sites.

Eight Success Stories

In January 2010, the Pennsylvania Patient Safety Authority analysts identified eight hospitals that had dramatically reduced their incidence of wrong-site surgery reports. The Patient Safety Officer at each facility kindly provided either information about facility efforts to eliminate wrong-site surgery or contact with personnel within the facility who did. To maintain confidentiality, the results of these unstructured interviews have been aggregated. The common themes of the interviews highlight the main efforts associated with the successes (see Table).

Table. Actions Cited by Eight Hospitals Implementing Successful Programs to Reduce the Risk of Wrong-Site Surgery (ordered by number of times cited) ​
Times CitedActions

Standardize policies and procedures across the facility.

Educate all physicians and nursing staff about problems, impact, solutions, and policies and procedures. Use cases, including near misses as motivation for change. Use role models to assist in the process. Use information from the Pennsylvania Patient Safety Authoritya to support evidence-based best practice.

Monitor results and compliance regularly, with independent observers, and provide results to all relevant audiences, including the facility's board of directors.

5Demonstrate leadership commitment and support.

Conduct root-cause analyses (RCAs) on all wrong-site events, including important near misses, and involve the physicians in the analyses.

Involve operating room (OR) staff, anesthesia providers, and surgeons in the development of consensus around appropriate policies and procedures.

Improve the use of a preoperative checklist for documentation verification and reconciliation.

Develop a highly scripted time-out that engages all OR team members in the time-out process, and educate personnel about the script.

Strictly enforce the agreed-upon policies and procedures, with peer review for repeatedly noncompliant physicians.


Share adverse events, near misses, and the results of RCAs with all relevant audiences, including the facility's board of directors.

Conduct a detailed review and refinement of the appropriate policies and procedures, using mock tracer methodology, results of RCAs of events, information from the Authority,a and consensus from members of the OR team.

Implement the World Health Organization surgical safety checklist.

Establish a policy that at least two people, including a physician and a nurse, participate in the time-out for any invasive procedure, including bedside procedures.

Establish a culture in which nurses are empowered to enforce policies and procedures, and can stop physician procedures if necessary for clarification.


Make prevention of wrong-site surgery a patient safety priority.

Use mock tracer methodology to improve processes.

Establish a sense of ownership by all involved in creating and following policies and procedures.

Post enlarged time-out scripts in each OR.

Follow up with a program for continued improvement of the processes.


Establish a surgical patient safety committee.

Assign responsibilities for solutions.

Make the intermediate objective of perfect compliance with Universal Protocol policies and procedures a goal, rather than making no wrong-site surgery a goal.

Implement changes one service at a time.

Focus on continuity of care.

Identify and eliminate look-alike and sound-alike terms.b

Emphasize the benefit to the patient.

Establish a culture of respectful interactions between physicians and nurses.

Have a program for explaining to patients the need for redundancy in asking questions.a

Insist on accurate consents.

Include anesthetic blocks in the procedures covered by the processes.

Start each day in each OR with a daily preview.

Do a formal patient identification on entering the OR.

a.  Pennsylvania Patient Safety Authority (Authority). Preventing wrong-site surgery [patient safety tool collection online]. [cited 2010 May 3].
     Harrisburg (PA): Authority. Available from Internet:

b.  Potentially dangerous abbreviation in surgery. PA PSRS Patient Saf Advis [online] 2004 Mar [cited 2010 May 3] Available from Internet: .


At the time these eight hospitals were identified in January 2010, each had gone a minimum of 64 weeks without wrong-site surgery (the last report having been submitted in early October 2008) and a maximum of 103 weeks, with an average of 81 weeks without any wrong-site surgery for the eight facilities. In the approximately 3.5 to 4.25 years prior to their respective improvements, the eight hospitals had reported 68 wrong-site surgeries, with a minimum of 6 and average of 8.5 per hospital for an average of one wrong-site surgery from each facility every 24 weeks, one every 3 weeks from the group as a whole. (See Figure 2.)

Figure 2. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports for Eight Hospitals with Successful Improvement EffortsFigure 2. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports for Eight Hospitals with Successful Improvement Effor


The actions cited by each facility in each interview were categorized and aggregated. They are listed, in the table, in the order of the number of hospitals that cited them. They will be discussed in chronological order.

Five of the eight hospitals discussed the importance of leadership: the initial commitment and the ongoing support of hospital leaders, including vice presidents for medical affairs, chief medical officers, medical staff presidents, department chairs, directors, and surgeons. Support included empowerment of OR staff who stopped procedures to resolve concerns and mentorship of noncompliant physicians.

In several facilities, the initiative to eliminate wrong-site surgery was part of an overall patient safety program within the facility. Two facilities made prevention of wrong-site surgery a high priority goal. One made specific individuals responsible for implementing the solutions and chose to measure results against the process standard of perfect compliance with the Universal Protocol instead of the outcome measure of zero wrong-site surgeries. Another facility established a surgical patient safety committee.

One of the most commonly cited strategic decisions—mentioned by three quarters of the successful hospitals—was to standardize practices, in most instances not only within the operating room (OR), but extending to the anesthesia block area, the entire facility, and even entire systems. As one facility representative said, “All on the same page. All the same way.”

Before deciding on a standard practice, five of the facilities specifically mentioned doing detailed assessments of their processes in one way or another, including root-cause analyses of wrong-site adverse events and near misses, with physician involvement in the analyses; use of mock tracer methodology; and information from the Authority.1

Half of the facilities specifically opined that involving the frontline OR personnel, including nurses, anesthesia providers, and surgeons, in the detailed improvement of the policies and procedures was critical to both their acceptance and their success. One person described the secret of success as “commitment from the top down; process from the bottom up.” One hospital described consciously seeking to build consensus. Two mentioned the importance of establishing a sense of ownership in all those involved in the processes by engaging them in the creation of the policies and procedures. One had all their providers sign off on the final, agreed-upon, results.

The most common revisions were in the preoperative checklist (half) and in the time-out script (half). Three cited implementation of the World Health Organization’s surgical safety checklist. Three identified the need to ensure that both a nurse and a physician were present to do a time-out for all invasive procedures, including bedside procedures throughout the hospital and anesthesia blocks. One hospital, perhaps mindful of the large percentage of wrong-site anesthetic blocks in the state,2 made a special effort to evaluate the processes for verifying the site for regional and local anesthetic blocks. One hospital added an educational program to explain to patients why questions were asked repeatedly by different providers, possibly using the patient education brochure developed by the Authority.1 One hospital included the elimination of look-alike and sound-alike terms in their reassessment, possibly based on reports referenced in the Pennsylvania Patient Safety Advisory.3

Another of the most commonly cited actions was to educate all the relevant healthcare providers, including the physicians, about the risks and causes of wrong-site surgery, the impact, any facility solutions, and the specifics of facility policies and procedures. Discussions of their own wrong-site surgeries and near misses, often by those who were involved, were done to illustrate vulnerability and to motivate change. As one facility representative said, “The pain of prior events helps others change behavior.” Several hospitals specifically mentioned the educational information available from the Authority.1

Three hospitals cited the importance of discussing the need to empower OR staff to halt the process if noncompliance, inconsistencies, or other concerns were noted. Leaders made it clear that OR staff would be supported when these situations arose. In some of the hospitals, this empowerment was part of a general discussion of respectful interactions between physicians and OR staff. In others, the emphasis was on the benefit to the patient: “It’s not about you. It’s not about me. It’s about the patient.”

Some hospitals focused on specific actions. One focused on the accuracy of the consents, specifically making sure they included a complete description of the site. Another focused on a formal identification of the patient upon entering the OR. Two made posters of their time-out script and put one in each room in the OR suite. One added a general briefing for each OR at the beginning of each day.

The last of the most commonly cited actions was to monitor compliance with the agreed-upon policies and procedures. Some monitored monthly, some weekly. Some used independent observers not otherwise associated with the process. Results provided feedback to the staff and physicians, who are being monitored. Results, in some hospitals, were also provided to the hospital’s board of directors. One hospital set a goal of perfect compliance with the Universal Protocol. Two hospitals explicitly mentioned using the results to fine-tune the processes to ensure continuous quality improvement.

Half of the hospitals made it clear that they were strict about compliance with the agreed-upon policies and procedures. “They learn to feel better when they get it right all the time,” said one representative. Nurses were empowered to halt the process if needed, with support of hospital management. Persistent noncompliance was considered a peer-review activity.

Listening to the interviews, the analysts were left with the impression that, like every other aspect of healthcare delivery, it is what you do and how well you do it that separates good performers from average performers.

The Wrong-Site Surgery Consultation Program

The Authority has begun an onsite consultation program for Pennsylvania facilities that wish to analyze their vulnerabilities for wrong-site surgery, particularly following a wrong-site event (or a close call) in a surgical suite. Requests can be made through the Authority office or the regional Patient Safety Liaison. The Authority clinical specialists will assist facilities in assessing their policies and procedures, measuring staff compliance, and thoroughly analyzing any events using resources developed by the Authority.1

The Authority is committed to having no patient experience wrong-site surgery.


  1. Pennsylvania Patient Safety Authority (Authority). Preventing wrong-site surgery [patient safety tool collection online]. [cited 2010 May 3]. Harrisburg (PA): Authority. Available from Internet:
  2. Quarterly update on the preventing wrong-site surgery project: improving, but still room for perfection. Pa Patient Saf Advis [online] 2009 Dec [cited 2010 May 3]. Available from Internet:
  3. Potentially dangerous abbreviation in surgery. PA PSRS Patient Saf Advis [online] 2004 Mar [cited 2010 May 3] Available from Internet:

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