title: Getting surgery right.
abstract: 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.
authors: Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA. jclarke@ecri.org
authors: John R
authors: JR
authors: Clarke
authors: Janet
authors: J
authors: Johnston
authors: Edward D
authors: ED
authors: Finley
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D010414:Pennsylvania / Q000453:epidemiology; D012307:Risk Factors; D012308:Risk Management; D017751:Safety Management; D013514:Surgical Procedures, Operative
references: Arch Surg. 2006 Apr;141(4):353-7; discussion 357-8
references: 16618892
references: J Perianesth Nurs. 2006 Oct;21(5):317-28; quiz 329-31
references: 17027441
references: J Am Coll Surg. 2007 Feb;204(2):236-43
references: 17254927
references: Am Surg. 2006 Nov;72(11):1088-91; discussion 1126-48
references: 17120952
references: Clin Orthop Relat Res. 2005 Apr;(433):26-9
references: 15805933
references: Mater Manag Health Care. 2006 Feb;15(2):55-6
references: 16583616
references: Bull Am Coll Surg. 2002 Dec;87(12):26
references: 17387987
references: Qual Saf Health Care. 2006 Dec;15 Suppl 1:i44-9
references: 17142609
references: Sentinel Event Alert. 1998 Aug 28;(6):1-2
references: 11892770
references: J Bone Joint Surg Am. 2003 Feb;85(2):193-7
references: 12571293
references: Jt Comm J Qual Saf. 2003 Jul;29(7):354-62
references: 12856557
references: J Perioper Pract. 2006 Feb;16(2):80-6
references: 16502740
references: AORN J. 2006 May;83(5):1115-8, 1121-2
references: 16722287
references: Arch Surg. 2006 Sep;141(9):931-9
references: 16983037
references: J Am Acad Orthop Surg. 2006 Apr;14(4):226-32
references: 16585364
references: Qual Saf Health Care. 2005 Feb;14(1):56-60
references: 15692005