Best Practices for Preventing Wrong-Site Surgery

Recently, we wrote about the importance of the time-out to prevent wrong-site, wrong-patient and wrong-procedure surgery. And while this perioperative pause is key to prevention, there are additional steps that medical facilities can and should take to minimize the risk of wrong-site surgery.

How big of a problem is this preventable medical error? In 2010, 463 incidents of wrong-patient, wrong-site and wrong-procedure surgery were voluntarily reported. The Joint Commission (TJC) estimates that the true number of incidents is much higher when unreported incidents are factored in — possibly as high as 50 incidents per week in the United States. More recently in 2020, 68 wrong-site surgeries were reported. And while the number appears to be trending in the right direction, TJC estimates that less than 2% of all sentinel events are reported.   

In addition to compromising patient safety and trust, wrong-site surgeries can have a lasting impact on a medical facility’s reputation, and exposes the organization to costly liability issues. While the creation of The Universal Protocol in 2004 has helped raise awareness of the issue, The Joint Commission has identified several common problem areas where there’s room for improvement.

wrong site surgery


Why is Wrong-Site Surgery Still an Issue?

The Universal Protocol lays out three important and seemingly simple steps that should be followed to prevent wrong-site surgery:

  • Conduct a pre-procedure verification process
  • Mark the procedure site
  • Perform a time-out

Unfortunately, these steps are not always followed — and when they are, errors and omissions often compromise their effectiveness. In 2014, The Joint Commission conducted a study in which eight U.S. hospitals and ambulatory surgery centers measured the risk of wrong-site surgery in their perioperative processes.

The report — Reducing the Risk of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project — highlights several common factors that increase the risk of wrong-site surgery, and provides specific solutions. The main factors that contribute to the risk of wrong-site surgery fall into four categories: scheduling, pre-op / holding, operating room and organizational culture.


Scheduling Problems and Solutions

Booking Documents
Busy schedulers often don’t verify the presence and accuracy of booking documents. It’s crucial to verify all booking documents before the day of surgery, including procedure orders and the patient chart. 

Verbal Bookings
Schedulers should never accept verbal requests for surgical bookings. The organization should enforce a policy that written requests must be submitted for all bookings.

Unclear Writing
Illegible handwriting, crossed-out text, and unapproved abbreviations often lead to a lack of clarity. Offices should be informed that unapproved abbreviations are unacceptable. Consent documents must be clear and correct, legible, and free of cross-outs. Consents that don’t meet these criteria should be returned for correction. 


Pre-op / Holding Problems and Solutions

Primary Documents
Documents such as consent, history and physical, surgeon’s booking orders, and operating room schedule are often missing, inconsistent or incorrect. Accurate primary documents should be required 48 hours before surgery. If inconsistencies are found, the operating room schedule should be flagged to alert staff — and the case should be treated as high risk.

Inconsistent site-markings often include: marks made with an unapproved surgical-site marker or sticker, inconsistent site marks used by surgeons, and someone other than the surgeon marking the site. Facilities should create a protocol requiring surgeons to  use a single-use surgical-site marker with a consistent mark (e.g., surgeon’s initials) as close as possible to the incision site.

Time-outs are often skipped, compromised or inconsistent due to distractions and rushing. They are frequently performed before all staff members are ready, or before prep and drape, and often lack full participation. Facilities should develop a role-based time-out process where every team member has an active role. They should always be performed after the prep and drape.

Patient Verification
Being rushed or distracted often leads to inadequate patient verification. Staff must be educated on the importance of following standardized verification protocols. It’s essential to create an environment where staff feel comfortable speaking up when there is a patient safety concern.


Operating Room Problems and Solutions

Intraoperative Site Verification
When a provider performs multiple procedures, intraoperative site verification is often skipped. It’s imperative that the provider stops between each procedure to ensure that the procedure, site and laterality of each procedure are performed accurately and according to the signed surgical consent.

Communication and briefing at hand-off is often ineffective. When the patient arrives in the operating room, verify the patient identity, procedure, site, side and any other critical information — ideally with patient involvement.

Primary Documentation
Primary documentation is often not used to verify patient, procedure, site and side
immediately prior to incision. Ensure that primary documentation is used during the time-out to verify the patient, procedure, site and side.

Site Marks
Site marks are often inadvertently
removed during prep. To prevent this common problem, use one-time-use indelible markers. Test pens for satisfactory results with commonly used prep solutions, and keep an adequate supply of effective markers in pre-op, holding and the operating room. After marking the surgical site pre-operatively with a marker, place a “Wrong Site Sleeve” on the “wrong limb” to avoid errors once the patient is taken to the OR. The safety sleeve’s fluorescent orange color alerts medical staff once again that “this is the wrong limb for surgery.”


Organizational Culture Problems and Solutions

Patient Safety
An organization’s focus on patient safety is frequently inconsistent. Facilities should develop a measurement system to identify inconsistencies in real time. All caregivers and staff members should be held accountable for their role in risk reduction.

Passive Staff
In many cases, the staff is not empowered to speak up when there’s a patient safety
concern. It’s the organization’s responsibility to create an environment where staff is encouraged to ask questions, participate and speak up when they have a patient safety concern.

Staff Education
Staff education is often insufficient, inadequate and inconsistent when there are policy
changes. Organizations are encouraged to use a team approach when teaching staff how a new process should be executed. Facilities should provide ongoing education and  just-in-time coaching — and are encouraged to celebrate successes and improvement.


Reducing the Risk of Wrong-Site Surgery

When hospitals incorporated the solutions above to the common problems that were identified in The Joint Commission study, the risk of wrong-site surgery was significantly reduced. The number of surgical cases with identifiable risks for wrong-site surgery were reduced by 46 percent in the area of scheduling, 63 percent in pre-op / holding, and 51 percent in the operating room.

Eliminating these preventable medical errors starts with prioritizing an enduring culture of safety, and taking steps to improve perioperative processes. Following these best practices from scheduling through incision can go a long way to minimize the risk of wrong-site surgery. Jackson Medical is committed to supporting patient safety in the OR. Find more tools and resources to support your organization’s safety efforts in our Resource Center.

Latest AORN Surgical Fire Safety Guidelines Hot SheetDownload