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Getting Surgery Right

Clarke, John R. MD*†; Johnston, Janet MSN, JD; Finley, Edward D. BS

doi: 10.1097/SLA.0b013e3181469987
Original Articles

Objective: We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).

Methods: We examined all reports from all hospitals and ambulatory surgical centers—in a state that requires reporting of wrong-site surgery—from the initiation of the reporting requirement in June 2004 through December 2006.

Results: Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%).

Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92.

Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing “wrong” surgery.

Conclusions: Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons’ best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.

All 427 experiences with wrong-site surgery reported to a statewide system over 30 months were analyzed: 174 reached patients, often before formal site verification. Wrong-side surgery dominated, primarily involving extremities and eyes. Surgeons and anesthesia providers were most often implicated; patients and nurses were most likely to correct errors.

From the *Department of Surgery, Drexel University, Philadelphia, Pennsylvania; and †ECRI Institute, Plymouth Meeting, PA and the Pennsylvania Patient Safety Reporting System, Pennsylvania Patient Safety Authority, Harrisburg, Pennsylvania.

Supported by a contract from the Pennsylvania Patient Safety Authority to the ECRI Institute.

Reprints: John R. Clarke, MD, Clinical Director of the Pennsylvania Patient Safety Reporting System, 5200 Butler Pike, Plymouth Meeting, PA 19462. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.