Patient Safety Topics
:
Wrong-Site Surgery
Overview

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.

Key Data and Statistics

Principles for Reliable Performance of Correct-Site Surgery

  1. The correct site of the operation should be specified when the procedure is scheduled.
  2. The correct operation and site should be noted on the record of the history and physical examination.
  3. The correct operation and site should be specified on the informed consent.
  4. Anyone reviewing the schedule, consent, history and physical examination, or reports documenting the diagnosis, should check for discrepancies among all those parts of the patient’s record and reconcile any discrepancies with the surgeon when noted.
  5. The surgeon should have supporting information uniquely found in the office records at the surgical facility on the day of surgery.
  6. All information that should be used to support the correct patient, operation, and site, including the patient’s or family’s verbal understanding, should be verified by the nurse, anesthesia provider, and surgeon before the patient enters the operating room (OR).
  7. All verbal verification should be done using questions that require an active response of specific information rather than a passive agreement.
  8. Patient identification should always require two unique patient identifiers.
  9. Any discrepancies in the information should be resolved by the surgeon, based on primary sources of information, before the patient enters the OR.
  10. The site should be marked by a healthcare professional familiar with the facility’s marking policy, with the accuracy confirmed both by all the relevant information and by an alert patient, or patient surrogate if the patient is a minor or mentally incapacitated; the site should be marked before the patient enters the OR.
  11. The site should be marked by the provider’s initials.
  12. All information that should be used to support the correct patient, operation, and site, including the patient’s or family’s verbal understanding, should be verified by the circulating nurse upon taking the patient to the OR.
  13. Separate formal time-outs should be done for separate procedures, including anesthetic blocks, with the person performing that procedure.
  14. All noncritical activities should stop during the time-out.
  15. The site mark should be visible and referenced in the prepped and draped field during the time-out.
  16. Verification of information during the time-out should require an active communication of specific information, rather than a passive agreement, and be verified against the relevant documents.
  17. All members of the operating team should verbally verify that their understanding matches the information in the relevant documents.
  18. The surgeon should specifically encourage operating team members to speak up if concerned during the time-out.
  19. Operating team members who have concerns should not agree to the information given in the time-out if their concerns have not been addressed.
  20. Any concerns should be resolved by the surgeon, based on primary sources of information, to the satisfaction of all members of the operating team before proceeding.
  21. Verification of spinal level, rib resection level, or ureter to be stented should require radiological confirmation, using a stable marker and readings by both a radiologist and the surgeon.

Data Snapshots

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

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

Pennsylvania Patient Safety Authority Wrong-Site Nerve Block Reports by Academic Year

 

More Snapshots​
Wrong-Site Operating Room Procedures Reports by Type 
Wrong-Site OR Procedures Reports by Type
Marking Experiences Listed by Markers 
Marking Experiences by Markers
Marking Experiences by Skin Preparation Agents  
Marking Experiences by Skin Preparation Agents
Flow of Information: Before Operation until Site Marking 
Flow of Information: Before Operation until Site Marking
The Awareness of Information in the Operating Room 
Awareness of Information in the OR
Associations for Key Best Practice Principles 
Associations for Key Best Practice Principles
Most Common, Independent Best Practice Principles 
Most Common, Independent Best Practice Principles
Survey of Elements 
Survey of Elements    
Elements of a Prevention Program and Success in Trapping Errors 
Elements of a Prevention Program and Success in Trapping Errors
Relative Ratios of Claims and Paid Claims by Specialties 
Relative Ratios of Claims and Paid Claims by Specialties
Percentage of Claims Paid and Average Payment for Paid Claims 
Percentage of Claims Paid and Average Payment for Paid Claims
Educational Tools

​Principles for Reliable Performance of Correct-Site Surgery
If surgical facilities are to hold their gains in consistently performing correct-site surgery, these principles for reliable performance of correct-site surgery, identified by the Pennsylvania Patient Safety Authority during its Preventing Wrong-Site Surgery Project, should be consistently followed.

Principles for Reliable Performance of Correct-Site Nerve Blocks
These principles can aid in the reduction of wrong-site nerve blocks and help sustain implementation of clinical practices.

Evidence Base for the Principles
Facilities may wish to use this information to inform surgeons and anesthesiologists on the rationale behind implementing best practices for following the Universal Protocol.

Actions to Satisfy Universal Protocol and WHO Surgical Safety Checklist
This crosswalk, developed by the Pennsylvania Patient Safety Authority, includes best practices to prevent wrong-site surgery that are endorsed by the Joint Commission, the World Health Organization, and the Authority.

How Can You Prevent Wrong-Site Surgery?
Surgeons or facilities can provide this brochure to preoperative patients so that they understand why so many providers ask the same questions. Facility-specific logos or contact information can be added to personalize the brochure.

Gaining Insight into Wrong-Site Surgery
This educational poster can be used to raise awareness about wrong-site surgery.

Patients and Surgical Teams Work Together to Avoid Wrong-Site Surgery
This poster incorporates the elements of the Universal Protocol and the Authority's Principles for Reliable Performance of Correct-Site Surgery to reflect the patient's perspective of the preoperative verification process to avoid wrong-site surgery. Facilities providing surgical services can post this tool to encourage patients, surgeons, and surgical teams to use - and remain engaged - in the process.

Gap Analysis and Action Plan to Prevent Wrong-Site Surgery
This tool provides surgical teams with the opportunity to identify potential practice gaps as compared with the 21 evidenced-based principles issued by the Authority.

Self-Assessment Checklist for Program Elements
This checklist can be used to evaluate and monitor facility programs for preventing wrong-site surgery.

Self-Assessment Checklist for Wrong-Site Anesthesia
This checklist can be used to evaluate and monitor facility programs for preventing wrong-site anesthesia.

OR Scheduling Form
This sample form includes suggested elements pertinent to scheduling cases for the operating room. 

Preoperative Checklist
This sample checklist includes suggested elements pertinent to checking patient information, medical documentation, and surgical information. 

Time-Out in the OR
In 2008, the Authority conducted a contest for facilities to submit scripts for time-outs in the operating room. Entries were posted to the Authority website.

Day of Surgery: Standardized Independent Verification 1
This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information.  It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure.

Day of Surgery: Standardized Independent Verification 2
This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information.  It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. 

For Surgeons' Offices: What You Can Do to Prevent Wrong-Site Surgery
This sample surgeon's office tip card and checklist can help in checking for discrepancies among different parts of the patient's record so that they may be reconciled with the surgeon.

Observational Monitoring Tool
This monitoring tool, which has been adapted with permission from the Health Care Improvement Foundation, can be used to monitor cases in the operating room. 

Observational Monitoring Tool for Wrong-Site Anesthesia
This monitoring tool can be used to observe regional or local anesthesia blocks in the operating room.

Compliance Monitoring Tool
This monitoring tool aligns observations with the goals and measurement standards associated with the 21 potential recommendations to prevent wrong-site surgery.

Monitoring of Preoperative Information from Surgeon's Office Available at First Encounter
This sample monitoring tool can be used to monitor 10 cases for availability of preoperative information during preadmission testing or preoperative admission.

Wrong-Site Surgery Error Analysis Form
Anyone faced with a wrong-site surgery near miss or occurrence in his or her facility is encouraged to use this form to aid in the analysis.

Wrong Ureter Analysis Form
This form is an addendum to the "Wrong-Site Surgery Error Analysis Form" and should complement the main form, as applicable.

Wrong Spinal Level Analysis Form
This form is an addendum to the "Wrong-Site Surgery Error Analysis Form" and should complement the main form, as applicable.

Multimedia
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
 
Advisory Articles

 

 
Safety Tips for Patients

 

 
Contact

Pennsylvania Patient Safety Authority
333 Market Street, Lobby Level
Harrisburg, PA 17101

Phone (717) 346-0469

Fax (717) 346-1090

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