Patient Safety Topics
:
Wrong-Site Surgery
Overview

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Recommendations

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

  • 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.

    The tool is a PDF and requires Adobe Reader to view and/or use the electronic entry feature

  • 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.

    The tool is a PDF and requires Adobe Reader to view it.

  • 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.

    ​Specific instructions for use are included in the form, which may be downloaded for electronic entry or printed for handwritten entry. The form is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.

    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.

    ​Specific instructions for use are included in the form, which may be downloaded for electronic entry or printed for handwritten entry. The form is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.​

  • 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.

    Specific instructions for use are included in the form, which may be downloaded for electronic entry or printed for handwritten entry. The form is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.

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.

    Specific instructions for use are included in the tool, which may be downloaded for electronic entry or printed for handwritten entry. The tool is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.

  • ​ 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.

    Specific instructions for use are included in the tool, which may be downloaded for electronic entry or printed for handwritten entry. The tool is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.​

  • 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.

    Specific instructions for use are included in the checklist, which may be downloaded for electronic entry or printed for handwritten entry. The checklist is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.​

  • Self-Assessment Checklist for Wrong-Site Anesthesia ​​​

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

    Specific instructions for use are included in the checklist, which may be downloaded for electronic entry or printed for handwritten entry. The checklist is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.

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

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

    Specific instructions for use are included in the tool, which may be downloaded for electronic entry or printed for handwritten entry. The tool is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.

  • 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.

    Specific instructions for use are included in the checklist, which may be downloaded for electronic entry or printed for handwritten entry. The checklist is a PDF and requires Adobe Reader​ to view and/or use the electronic entry feature.​​

​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.

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. These principles accompany the article "Quarterly Update: What Might Be the Impact of Using Evidence-Based Best Practices for Preventing Wrong-Site Surgery?​" in the September 2011 issue of the Pennsylvania Patient Safety Advisory.
Facilities may wish to use this information to inform surgeons and anesthesiologists on the rationale behind implementing best practices for following the Universal Protocol.

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.​
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
Articles
Safety Tips for Patients