Pa Patient Saf Advis 2016 Jun;13(2):77-78.
Update on Wrong-Site Surgery: Use Patient Engagement to Enhance the Effectiveness of the Universal Protocol
Anesthesiology; Nursing; Surgery
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Theresa V. Arnold, DPM
Manager, Clinical Analysis
Pennsylvania Patient Safety Authority


From July 2004 through March 2016, 689 wrong-site surgery events were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority. The three most common types of wrong-site operating room (OR) procedures reported through PA-PSRS since July 2004 continue to persist and account for more than 50% of events (N = 689):       

  1. Anesthetic blocks by anesthesiologists and surgeons (26.6%, n = 183)
  2. Wrong-level spinal procedures (12.8%, n = 88)
  3. Pain-management procedures (11.5%, n = 79)
Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year

 Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year


The overall percentage for wrong-site anesthetic blocks decreased slightly from the previous analysis (i.e., 27.4% to 26.6%); however, the percentage of wrong-level spinal procedures and pain-management procedures remained consistent.

Although the 2014-2015 academic year* proved challenging,1 the 2015-2016 academic year has shown improvement, especially in the second and third quarters. If the trend of the past two quarters continues into the final quarter, results at the conclusion to the academic year may be comparable to previous years.      

Forty-two events were reported from Pennsylvania ORs in the first three quarters of the 2015-2016 academic year; 21 in the first quarter, 12 in the second quarter, and 9 in the third quarter. Wrong-site anesthesia blocks, which predominate in the overall number of events above, accounted for14.3% (n = 6 of 42), 4 of which were administered by an anesthesiologist and 2 by surgeons.

The other types of wrong-site surgery events were as follows:
  • Wrong-side procedures (23.8%, n = 10 of 42), only one of which was identified as an orthopedic procedure
  • Wrong-side pain-management procedures (e.g., wrong-side spinal injections; 16.7%, n = 7)
  • Misidentified spinal levels (14.3%, n = 6)
  • Wrong procedures—two of which described the removal of the wrong organ (11.9%, n= 5)
  • Wrong-site procedures (11.9%, n = 5), two of which were wrong-site hand procedures (e.g., carpal tunnel release instead of trigger finger release)
  • Wrong-side ureteroscopy/ureteral stent placements (7.1%, n = 3)

* This includes an additional event reported in the third quarter of the 2014-2015 academic year.

The Authority Celebrates 2016 National Time Out Day with Patient-Centered Poster

Although the number of wrong-site events has shown steady, yet slow improvement since the 2007–2008 academic year, 2014-2015 proved to be a challenge for facilities because the number of events increased 25.5% from the previous academic year, which had the lowest number of events reported to the Authority since data collection began in 2004. With implementation of the Universal Protocol, surgical teams have been guided through a three-step process of patient identification, procedure site marking, and time-out.2 How effectively has this process taken hold in Pennsylvania healthcare facilities providing surgical services? Are surgical teams—and patients—engaged in the process or are they merely going through the motions to follow a policy? Is the process precisely defined or is there significant variation in the manner in which the Universal Protocol is performed—a potential byproduct of a nonprescriptive protocol? Recognizing these possibilities and the current focus on delivering patient-centered care, the Authority captured the elements of the Universal Protocol, simplified it to reflect a patient’s perspective of the process, and created a poster: Patients and Surgical Teams Work Together to Avoid Wrong-Site Surgery. The poster was released to coincide with the Association of periOperative Registered Nurses (AORN) National Time Out Day celebrated on June 8, 2016.3

Tips for Successful Patient Engagement in the Universal Protocol

Patients and Surgical Teams Work Together to Avoid Wrong-Site Surgery highlights the three main steps of the Universal Protocol: pre-procedure verification, procedure site marking, and procedure time-out. Although the title speaks to both patients and surgical teams, it emphasizes the patient as the first-person narrator. The format serves two purposes: (1) it reminds surgical teams that patient engagement is integral to the process, and (2) it informs patients of the tiered approach the surgical team is expected to complete to ensure that the proper procedure is performed on the correct patient and at the correct site. When demonstrated, explained, and reviewed, this information can empower the patient. Engaging patients as partners may also prove beneficial for surgical teams because patients in this role set a standard for staff accountability to ensure that the process is carried out as anticipated. The elements of the poster follow.

Preoperative Verification

  • Identify the patient using two forms of identification that require an active response (e.g., “What is your name and date of birth?”).4
  • Meet and speak with the patient and their caregiver preoperatively to confirm their understanding of the correct procedure, site, and side.4
  • Ensure that the correct procedure, site, and side are documented on all source documents including the OR schedule, informed consent(s), and the patient’s history and physical.2,4 By analyzing events and participating in time-out observations, the Authority realized that the correct site and side are not consistently specified on all source documents.

Procedure Site Marking

  • Include and use the patient or their caregiver as a resource in marking the site.2,4 Ensure that the information received from the patient is consistent with all the source documents and with the surgeon’s plan recollection of the correct procedure, site, and side.

Reference the Mark Before the Procedure Begins

  • Look for and use the mark as if it were the “patient’s voice” to orient the surgical team to the correct site once the patient is in the OR.4 Much time and effort is taken to make the mark; recognize the value of that effort by looking for and acknowledging the mark during each and every time-out.
  • Ensure that the mark is visible in the prepped and draped field.2,4
  • Stop all non-life-support activity during the time-out and encourage staff to actively participate (i.e., use active responses to questions rather than mere agreement).2,4
  • Empower staff to “speak up” on behalf of the patient and the surgical team if any team member has questions or concerns.2,4


  1. Arnold TV. Quarterly update on wrong-site surgery: eleven years of data collection and analysis [online]. Pa Patient Saf Advis 2015 Sep [cited 2016 Apr 29].;12(3)/Pages/119.aspx
  2. The Joint Commission. The Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery [poster online]. [cited 2016 May 1].
  3. AORN. National Time Out Day [online]. [cited 2016 Jun 1].
  4. Pennsylvania Patient Safety Authority. Principles for reliable performance of correct-site surgery. [cited 2016 Apr 29]. 

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