Pennsylvania hospitals implement wrong-site best practices

More than 30% of Pennsylvania healthcare facilities have successfully implemented 21 potential recommendations for preventing wrong-site surgery, according to the Pennsylvania Patient Safety Authority (PPSA).

The PPSA recently sent 417 Pennsylvania facilities with operating rooms its 21 potential recommendations to prevent wrong-site surgery and asked the facilities to describe barriers for implementing the recommendations that would prevent them from meeting the standard or standards for the goal.

The PPSA survey divided the 21 potential recommendations into five groups, with a total of six goals and eight proposed measurement standards for the groups. For each of the six goals, the PPSA asked facilities to describe barriers for successful implementation. Seventy facilities responded to the survey. Two-thirds of the responses were from hospitals, and one-third were from ambulatory surgical facilities, says John Clarke, MD, clinical director of the PPSA.

“Overall, the surveyed Pennsylvania healthcare facilities felt they could successfully implement the potential recommendations for preventing wrong-site surgery,” Clarke says. “Less than 20% of surveyed healthcare facilities identified some barriers to implementation, but all of the barriers could be modified or overcome through education, policy changes, or culture changes.”

Pennsylvania healthcare facilities responding to the survey gave their reasons for successful implementation of the 21 potential recommendations to prevent wrong-site surgery. “Education, audits, leadership, and empowerment of nurses to ‘stop the line’ were some of the strategies facilities cited they have used to successfully implement wrong-site surgery best practices,” Clarke says. “Elaboration of these strategies includes leadership buy-in from surgery departments and respectful interactions with staff.”

Clarke added that 27 facilities commented about the feasibility and potential cost impact of implementing the potential recommendations associated with each of the eight standards. “Most respondents — 20 out of 27 — had no concerns, indicating that the potential recommendations were in place or that they thought implementation was feasible at minimal cost,” Clarke said. “Seven expressed primarily cost concerns.”

Concerns about potential cost impact include: personnel time to verify and reconcile information, resources to monitor compliance, personnel time for redundant checking of information, resources needed to implement the evidence-based best practices, resources and time for education, resources to upgrade electronic and paper documents, possible increased staffing, OR delays and loss of business, and physician availability on-site or remotely for a second verification of intraoperative images.

Clarke adds that physician behavior and accessing accurate information before the patient’s arrival in the preoperative holding area were cited by surveyed Pennsylvania healthcare facilities as common barriers.

The PPSA’s program to prevent wrong-site surgery began in December 2007 after research revealed that Pennsylvania healthcare facilities were submitting about two and one-half wrong-site surgery reports per week. Since the prevention program began, wrong-site surgeries in Pennsylvania have decreased by 37% from an average of 19 reports per quarter to an average of 12 reports per quarter.

In April 2012, the PPSA began another wrong-site surgery initiative with 28 Pennsylvania healthcare facilities that have made the commitment to reduce and eliminate wrong-site surgeries.


  • John Clarke, MD, Clinical Director, Pennsylvania Patient Safety Authority, Harrisburg. Telephone: (717) 346-0469.