Current protocols can prevent many wrong-site surgeries if they are properly followed, a Pennsylvania watchdog agency reports.


The state’s Patient Safety Authority (PSA) analyzed 155 wrong-site incidents that occurred between July 2004 and December 2007. It also audited six volunteer hospitals, four of which reported at least one wrong-site surgery during those 2.5 years.

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“Wrong-site errors usually result from either misinformation prior to the patient getting into the operating room or misperceptions of hospital staff once the patient is in the operating room,” explains PSA clinical director John Clarke, MD. He cited right/left confusion and “the failure to question authority” as major reasons misperceptions don’t get corrected.


In addition, wrong-site surgery errors were associated with failure to identify incorrect information in documents, including schedules, consents and the patient’s history, Dr. Clarke observes.


The review found 25 incidents resulted strictly from misinformation and 45 resulted from misperception, a ratio of 1:2. The rest were mixed or ambiguous.


“Hospitals that check for errors at every opportunity have more success in preventing misinformation from reaching the OR,” the report observes. “The more independent checks, the better.”


The agency is now assessing information on near-misses. Preliminary data show that every report of an incident where a wrong surgery was averted mentioned using checklists to confirm documents and data.


Many errors slipped through because of a “confirmation bias, a tendency to confirm a mental impression despite the physical facts,” the report notes. It mentions incidents where nurses or other OR personnel either kept silent when they saw a mistake or were ignored and “a lack of engagement by some surgeons, anesthesia providers, and scrub technicians.”


“For a time-out to be effective, the OR team members must not only be engaged, they must be prepared to speak up,” it states.


For the complete report, as well as a prevention toolkit, go to