Wrong-site surgery is No. 1 among sentinel events — Are you at risk?

For the fist time since The Joint Commission began keeping records of sentinel events in 1996, wrong-site surgery has reached the No. 1 position over patient suicide in terms of cumulative data. There have been 552 reports of wrong-site surgery, yet it is viewed as an event that often is underreported.

Additionally, The Joint Commission says that in its 2006 surveys, 30% of hospitals, 28% of ambulatory organizations, and 16% of office-based surgeons failed to follow the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

In Rhode Island, the state health department recently intervened with an immediate compliance order after a hospital reported its second wrong-site surgery in a year and its third in six years.1 State officials ordered the hospital to hire a consultant and to have two physicians identify the correct surgical site before each procedure. The action came after a neurosurgeon operated on the wrong side of a patient's head July 30. The hospital suspended the surgeon, and the health department ordered him to stop performing surgery and undergo an evaluation.

A preliminary investigation indicated the surgical team did not take a "timeout" before beginning the procedure to double-check the correct location and other critical information, according to Bruce W. McIntyre, JD, a lawyer for the state Board of Medical Licensure and Discipline, which conducted a preliminary investigation of the doctor's actions.2

The surgeon had incomplete paperwork and relied on his memory, according to a Health Department investigation.3 A nurse practitioner employed by the surgeon did not record which side needed surgery in the patient's medical history nor on the consent form signed by a relative, according to a published report.3 When a circulating nurse in the OR pointed out that the information was missing, the surgeon wrote the side where he would operate, which was wrong, on the consent form, the report said. The 86-year-old man who underwent the surgery died the next month, and the medical examiner's office is trying to determine whether the surgical error contributed to his death, according to the report. A representative from the hospital's parent company said she believed someone in the OR had questioned whether the correct side was being cut, but the surgeon was confident he was right.3

At two recent meetings of The Joint Commission Professional Technical Advisory Committee (PTAC), members have commented that it is alarming that correct site surgery continues to be a problem.

While the increased number of wrong-site surgery sentinel events may be due to better awareness and reporting, the fact is that there continue to be wrong-site surgeries, and they can be avoided, sources say. "Regardless [of the reasons], it is not acceptable that the errors are still occurring," says Bonnie G. Denholm, RN, MS, CNOR, perioperative nursing specialist at the Center for Nursing Practice at AORN and a member of PTAC.

Compliance is the key problem, says David Wong, MD, MSc, FRCS(C), chairman of the Patient Safety Committee for the North American Spine Society and past chair of the Patient Safety Committee for the American Academy of Orthopaedic Surgeons in Chicago. "So we still get physicians saying, I'm on top of this; it's never going to happen to me. This is another extra step I have to make in pre-op protocol. I don't have time, and I don't see the value,'" Wong says.

And the problem isn't limited to surgeons, says Kate Moses, RN, CNOR, CPHQ, a representative from the Association of periOperative Registered Nurses (AORN) to PTAC and chair-elect of AORN's Ambulatory Specialty Assembly. Moses also is a quality management nurse at Medical Arts Surgery Centers (MASC) in Miami.

"Members of the team do not all take the time out process seriously," she says. "They appear to have an 'It won't happen to me,' or 'It doesn't apply to my role' attitude. Not everyone is made to pay attention and participate."

The No. 1 problem? Lack of effective communication, Moses says.

The Joint Commission reported that in nearly 80% of wrong-site surgeries reviewed from 1995 to 2005, communication was identified as a root cause.4 For example, whether through experience or lack of organizational/administrative support, members of the surgical team may not feel empowered to stop processes from moving forward when there is a discrepancy in the procedure at any point where a verification should be taking place, especially during the timeout, Moses says.

There are many other facets to the problem, she says. "Having reviewed policies from several organizations, many are not specific enough — too many holes in the 'Swiss cheese,' so to speak," Moses says. "They allow too much leeway for errors to occur." For example, policies may not demand that a site be part of the consent when applicable, the operating physician may not be mandated to mark the site, and site marking itself may be ambiguous and inconsistent, she says.

"Many facilities have 'timeout' policies/procedures, but they are not proscriptive enough to ensure compliance, and many facilities do not track compliance and make staff aware of the results of the tracking," Moses says. "It only becomes an issue when an event occurs."

Additionally, managers at some nonaccredited organizations may choose not to comply with national safety initiatives, including the universal protocol, she says.

Take these steps

So what is the solution?

Managers, surgeons, and staff must see the value of avoiding wrong-site surgery, sources say. "I think the big thing is that while it's a rare complication, it's a catastrophic one for patients and medical providers involved," Wong says.

Earlier this year, the World Health Organization's (WHO) Collaborating Centre for Patient Safety Solutions released nine solutions to prevent health care errors that included wrong-site surgery. WHO officials say a major contributing factor to these types of errors is the lack of a standardized preoperative process. Their recommendation? A preoperative verification process; marking of the operative site by the provider who will do the procedure; and having the team involved in the procedure take a timeout immediately before starting the procedure to confirm patient identity, procedure, and operative site.

Some states are getting involved. The Florida Board of Medicine has enacted a "pause rule" that requires the surgical team to pause before a procedure to confirm the side, site, patient identify, and surgery/procedures. (To view the rule, go to www.doh.state.fl.us.)

A comprehensive policy should follow the guidelines of the universal protocol and have the buy-in and support of all members of the surgical team, as well as administration, Moses says. Mandatory compliance with such a policy has proven to be the best method of turning a sentinel event into a near-miss, she says. "Unfortunately, there is still the human factor involved, and we may never be able to eliminate the errors completely," she says.

Continue educating your staff, Moses advises. "Support your staff by empowering them to say, 'STOP!' when discrepancies are identified," she says. Use tools such as the correct site surgery tool kit offered by AORN, Moses advises. (To access the tool kit, go to www.aorn.org/.)

"Hopefully, with guidelines that AORN has provided those of us in the ambulatory setting, and accreditation and regulatory standards, we can minimize the risks," she says.


  1. Rhode Island Department of Health. HEALTH to Review Neurosurgery Practices at Rhode Island Hospital. Aug. 2, 2007. Accessed at www.health.ri.gov/media/070802.php.
  2. Freyer FJ. R.I. Hospital cited for wrong-site surgery. The Providence Journal, Aug. 3, 2007. Accessed at www.projo.com.
  3. Freyer FJ. Surgeon relied on memory, not CT scan. The Providence Journal, Aug. 24, 2007. Accessed at www.projo.com.
  4. Joint Commission on Accreditation of Healthcare Organizations. Root causes of wrong site surgery (1995-2005). Accessed at www.jointcommission.org. (Accessed 29 March 2006).


For more information on wrong-site surgery, contact:

  • Kate Moses, RN, CNOR, CPHQ, QualityManagement Nurse, Medical Arts SurgeryCenters (MASC), 8940 N. Kendall Drive, No.201E, Miami, FL 33176. Phone: (786) 596-7556.E-mail: KateM@baptisthealth.net.

A wrong-site, wrong-procedure, and wrong-per-son universal protocol has been required by theJoint Commission on Accreditation of HealthcareOrganizations since July 2004. For access to the uni-versal protocol, a free one-hour audio conference on wrong-site surgery and a synopsis of the Second Wrong Site Surgery Summit held June 21, 2007, go to www.jointcommission.org. For more information about wrong-site surgery from the Joint Commission International Center for Patient Safety, including copies of the Sentinel Event Alert on wrong-site surgery, go to www.jcipatientsafety.org/22813.