• John R Clarke, Janet Johnston, and Edward D Finley.
• Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA. jclarke@ecri.org
• Ann. Surg. 2007 Sep 1; 246 (3): 395405395-403, discussion 403-5.

ObjectiveWe sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).MethodsWe 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.ResultsOver 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.ConclusionsWrong-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.

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