Pa Patient Saf Advis 2012 Dec;9(4):149.
Wrong-Site Surgery Protocol Followed
Anesthesiology; Nursing; Surgery
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While wrong-site surgeries receive lots of attention, there are many examples of healthcare workers preventing wrong-site surgery in Pennsylvania hospitals. The following reports illustrate the importance of multiple checks of the surgical consent, surgical markings, and communication among staff, patients, and family members.

The procedure on the operating room schedule was listed as left cataract extraction. All of the patient’s paperwork, history and physical, operation consent, physician’s orders, and patient preregistration form all state right cataract extraction. The incorrect side [on the schedule] was noted during verbal verification of the side during the registration process with the patient. The correct side, right, was then verified with the patient and the surgeon.

A surgical permit on [the patient’s] chart . . . [was] signed by the mother of another patient. The permit should have said one eye; this [consent indicated] both eyes. The [staff] noted the wrong parental signature. Another [correct surgical] permit was obtained from the parents.
The operating room manager schedule stated a right-side hernia repair. All documentation, [including the] consent, [indicated] the left [side]. The surgeon marked the right side in error. A registered nurse handoff communication identified the error.

These reports exemplify the importance of the Universal Protocol1 and of effective communication among staff, patients, and family members in preventing the occurrence of wrong-site surgeries.


  1. Pennsylvania Patient Safety Authority. Possible integration of actions to satisfy Joint Commission Universal Protocol and WHO Surgical Safety Checklist [online]. 2011 [cited 2012 Nov 1].

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