Patient Safety Topics
Wrong-Site Surgery


PATIENT SAFETY AUTHORITY/DEPARTMENT OF HEALTH Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks​​
[52 Pa.B. 1716] [Saturday, March 19, 2022] This document outlines final recommendations to hospitals, ambulatory surgery facilities, birthing centers and abortion facilities in this Commonwealth to ensure the correct procedure is performed on the correct site, side and patient.​

​Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process.


Educational Tools

​​​​​​​PSA Research and Commentary 2023

PSA WSS Prevention Foundation Documents

Pre-Surgery Checklists/Tools

WSS Investigational Tools

Compliance Checklists/Tools

Proactive WSS Prevention Educational Material

​Historical/Strategy PSA WSS Documents (prior to 2022 recommendations)

​​Gap Analysis and Action Plan to Prevent Wrong-Site Surgery
This tool helps to identify potential practice gaps as compared with the 21 evidence-based principles issued by the Patient Safety Authority (PSA)​​. 

Strategies to Reduce the Likelihood of Wrong-Site Surgery

Education tool to reduce the likelihood of wrong-site surgery.

Principles for reliable performance of correct-site surgery.​

Rationale to implement best practices regarding the Universal Protocol.

Principles for Reliable Performance of Correct-Site Nerve Blocks
Principles to help in the reduction of wrong-site nerve blocks.

Reliable Performance of Correct-Site Nerve Blocks

Wrong-Site Surgery Prevention—Using Interprofessional Collaboration to Improve Outcomes

Preventing Wrong-Site Surgery in Pennsylvania

Anesthesia Time-Outs—Why Are They Necessary?

Doing the "Right" Things to Correct Wrong-Site Surgery
Safety Tips for Patients