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

• Wrong-Site Surgery in Pennsylvania During 2015-2019: A Study of Variables Associated With 368 Events From 178 Facilities
• Online Supplement to “Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities
• Wrong-Site Surgery: Does That Really Happen?

PSA WSS Prevention Foundation Documents

• PATIENT SAFETY AUTHORITY/DEPARTMENT OF HEALTH Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks  

Pre-Surgery Checklists/Tools

• 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. Specific instructions for use are included in the tool, which may be downloaded for electronic entry and automatic calculation or printed for handwritten entry.
  

• 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.
  

• 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.​

• 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.​
  

WSS Investigational Tools

• 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.

  A "Wrong Spinal Level Analysis Form" and "Wrong Ureter Analysis Form​" were released as addendums to this main form and should complement it, as applicable.​
  

• 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..

Compliance Checklists/Tools

• Compliance Monitoring Tool ​​​

  This monitoring tool aligns observations with the goals and measurement standards associated with the 21 principles to prevent wrong-site surgery..

• ​ 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.​

• Self-Assessment Checklist for Program Elements Associated with Preventing Wrong-Site Surgery​​ ​​​

  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.

• Observational Monitoring Tool for Wrong-Site Anesthesia ​​​

  This monitoring tool can be used to observe regional or local anesthesia blocks in the operating room.

• 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.​

Proactive WSS Prevention Educational Material

• How Can You Prevent Wrong-Site Surgery? ​​​ ​​​ ​​​
  ​Surgeons or facilities can give 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.​
• 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 download (set to print at 18 x 24 inches) and display this poster to encourage patients, surgeons, and surgical teams to use—and remain engaged—in the process.​
• Self-Assessment Checklist for Wrong-Site Anesthesia ​​​

  This checklist can be used to evaluate and monitor facility programs for preventing wrong-site anesthesia.​​

​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)​​. ​