Is your office helping you prevent wrong site surgery?

The Pennsylvania Patient Safety Authority (the Authority) was established in 2002 under the state’s Medical Care Availability and Reduction of Error Act to collate for analysis preventable adverse events and near-misses at acute health care facilities. Hospitals, ambulatory surgery centers, and other facilities are required to report these events to the Authority. These reports are then analyzed to develop evidence-based best practices for the delivery of health care that may be implemented to reduce the risk of harm from these serious events and incidents.

One preventable adverse event that the Authority has focused on is wrong site surgery. The Authority has determined that wrong site surgery occurred, on average, once in every 63,603 procedures performed in operating suites and ambulatory surgical centers in Pennsylvania from July 2010 to June 2011. These data represent a 45 percent decrease in incidence from July 2007 to June 2008, when the Authority began a wrong site surgery prevention program.1 The decrease has been attributed to the collaborative efforts of the surgeons, anesthesia professionals, and perioperative staff at, now, 76 facilities in the state who have implemented best practices for preventing wrong site surgery.2-5

The best practices focus on preventing misinformation from entering the operating room (OR) and avoiding misperceptions in the surgical suite.6 One of the best practices calls for ensuring that detailed, accurate information is communicated from the surgeon’s office to the perioperative area.4 This article documents the effects of miscommunication between the surgeon’s office and the operating suite and offers recommendations on how to ensure that the correct information is conveyed.

Wrong site surgery defined

Wrong site surgery may occur in one of several ways, including operating on the wrong patient, performing the wrong procedure, operating on the wrong body part, or performing the procedure on the wrong side of the body. Although the likelihood of doing wrong site surgery is very low for any individual operation, the consequences are high. Any wrong site event dissipates the patient’s trust and adds significantly to health care costs. Claims payments for wrong site surgery average $158,560 adjusted to 2013 dollars.7 In addition, the volume of operations performed at an institution enhances the risks of wrong site procedures accumulating over time; for example, research suggests that there is a 5 percent risk for every 3,263 procedures, a 10 percent risk for 6,702 procedures, and a 20 percent risk for 14,193 procedures performed.8

Reports in Pennsylvania

From July 2004 to June 2013, the Authority received 541 reports of wrong site procedures occurring in operating suites and ambulatory surgical centers. A review of these reports reveals that 59 patients (11 percent, or one out of every nine patients) experienced wrong site surgery due to the facility receiving incorrect or incomplete information from the surgeon’s office. Those miscommunications resulted in the following:

  • A total of 34 (58 percent) operations on the wrong side
  • Two (3 percent) at the wrong spinal level
  • Eight (14 percent) at another wrong location, such as the wrong finger
  • A total of 15 (25 percent) involving the wrong procedure

The proportion leading to wrong procedures is significantly higher than in the registry as a whole (8 percent, p<0.001 by the chi-square test).

Misinformation from Surgeons’ Offices Identified in 541 Reports of Wrong Site Surgery

Misinformation from Surgeons’ Offices Identified in 541 Reports of Wrong Site Surgery

The proportion of wrong site events resulting from incorrect or incomplete information from the surgeon’s office was significantly higher, according to the chi-square test, than in the registry as a whole for wrong-side colectomies (accounting for all of the seven in the registry), wrong-side ureteral stents (seven of 29), insertions of the wrong device (six of 13), wrong site otolaryngology procedures (five of 19), and wrong site vascular procedures (three of six).

As noted in the table, a single piece of misinformation was implicated in 34 cases of wrong site surgery, two pieces of misinformation in 23 cases, and three pieces in the remaining two cases. The 11 types of misinformation that were provided also are listed in the table. Information that was incorrect or insufficiently specific when scheduling the case or obtaining the consent was, by far, the most common cause, and mentioned in 50 of the 59 reports. The 47 reports that mentioned only incorrect and/or inadequate information for the schedule and/or consent represented the identified causes of 9 percent of all 541 wrong site procedures—one out of every 11.

Effects of misinformation: Examples

The types of misinformation that occur between referring physicians’ offices and the surgeon’s office and the operating suite are wide ranging. The following contextually de-identified excerpts from reports of wrong site surgery to the Authority illustrate the results of incorrect and/or insufficient information from the surgeon’s office:

  • Procedure was inaccurately scheduled from physician’s office as [a] lumpectomy with sentinel lymph node biopsy. Consent was obtained for lumpectomy with axillary node dissection. Patient was injected for sentinel node biopsy.
  • Patient needed right popliteal thrombectomy. Consent obtained for left popliteal thrombectomy. Time-out performed prior to start of case; consent checked…. Skin incision made in the left leg.
  • Patient…found to have colon mass in right colon on colonoscopy. Patient referred to surgeon…scheduled for left colectomy. Patient admitted for left colectomy; permit was for left colectomy; and left colectomy was done. Patient returned [later]…for follow-up colonoscopy—found to have the same mass as prior.
  • Patient signed permit for laryngoscopy with biopsy. Patient was aware that the biopsy was to be of his tongue; however, it was to be done on the left side. Instead, it was done on the right side.
  • Patient was scheduled for an L3-4 hemilaminectomy and excision of herniated disk. No laterality was identified by the physician when scheduling, nor was laterality identified on the consent. In pre-operative holding, the lumbar area of the back was marked. The surgeon performed a left L3-4 hemilaminectomy and excision of herniated disk. [In postoperative follow-up,] the surgeon realized the procedure was done on the incorrect side.
  • Doctor’s office incorrectly scheduled the case. Schedule read ureteroscopy with possible insertion of stent. Patient’s consent read right ureteroscopy with possible insertion of  stent…. A surgical time-out was completed in the room and staff confirmed with the consent and the surgeon: right ureteroscopy with possible insertion of stent. After completing the procedure, the surgeon reviewed his office record and noted that the procedure should have been completed on the left side.

Best practices

The Authority has developed a set of best practices for surgeons to use to prevent wrong site surgery. These guidelines include the following:4,5

  • Provide accurate and sufficient information when scheduling the procedure. Information about the type and location of the procedure is sufficient if the perioperative staff can identify any deviation between what was intended and what is being done.
  • Provide accurate and sufficient information when obtaining the consent—ideally when the patient makes the decision to have the procedure done.
  • Provide accurate and sufficient information on the history and physical examination.
  • Have office staff check all documents necessary for the procedure for consistency and identify any inconsistencies requiring reconciliation. This can be done with the aid of a simple checklist or monitoring tool.9,10
  • Make sure that all documents needed for the procedure accurately reflect the office notes and diagnostic reports.
  • If information changes, verify with the appropriate perioperative services that all the updated information has replaced the original information.

By adhering to these standards, office staff can help prevent wrong site surgery.

Some of the information in this article was presented at the 2013 Annual National Surgical Quality Improvement Program (ACS NSQIP®) National Conference in San Diego, CA.


  1. Clarke JR. Quarterly update on preventing wrong-site surgery. Pennsylvania Patient Safety Advisory. June 2012. Available at:;9(2)/Pages/69.aspx. Accessed November 1, 2013.
  2. Pelczarski KM, Braun PA, Young E. Hospitals collaborate to prevent wrong-site surgery. Patient Saf Qual Healthc. 2010;7(5):20-26.
  3. Clarke JR. Quarterly update: What might be the impact of using evidence-based best practices for preventing wrong-site surgery? Results of objective assessments of facilities’ error analyses. Pennsylvania Patient Safety Advisory. December 2011. Available at: Accessed November 1, 2013.
  4. Clarke JR. Quarterly update on preventing wrong-site surgery. Pennsylvania Patient Safety Advisory. March 2012. Available at:;9(1)/
    . Accessed November 1, 2013.
  5. Pennsylvania Patient Safety Authority. Principles for reliable performance of correct-site surgery. December 2010. Available at: Accessed November 1, 2013.
  6. Clarke JR, Johnston J, Blanco M, Martindell DP. Wrong-site surgery: Can we prevent it? Adv Surg. 2008;42:13-31.
  7. Pennsylvania Patient Safety Authority. Quarterly update on the preventing wrong-site surgery project. Pennsylvania Patient Safety Advisory. September 2008. Available at: Accessed November 1, 2013.
  8. Clarke JR, Arnold TV. Quarterly update on wrong-site surgery: Work to be done. Pennsylvania Patient Safety Advisory. September 2013. Available at:;10(3)/Pages/110.aspx. Accessed November 1, 2013.
  9. Pennsylvania Patient Safety Authority. For surgeons’ offices: What you can do to prevent wrong-site surgery. March 2012. Available at:
    . Accessed November 1, 2013.
  10. Pennsylvania Patient Safety Authority. Monitoring of preoperative information from surgeon’s office available at first encounter. March 2012. Available at:
    . Accessed November 1, 2013.

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