Wrong site surgery near misses and actual occurrences

AORN J. 2009 Aug;90(2):215-8, 221-2. doi: 10.1016/j.aorn.2009.07.010.


Under coordination by the Patient Safety Authority, staff members in facilities across Pennsylvania analyzed 97 wrong site surgery near misses and 44 actual occurrences using a common analysis form from August 2007 to August 2008. These assessments were aggregated and compared by the Patient Safety Authority. Assessments in which near misses were identified that did not advance to actual wrong site occurrences were significantly more likely to report compliance with patient identification and preoperative reconciliation protocols, accurate scheduling, notation of the surgical site on the consent form, participation of the surgeon in preoperative verification, participation of all surgical team members in the time out, time outs performed with the site marking visible after draping, and the surgeon explicitly empowering team members to speak up if concerned and acknowledging concerns when expressed.

Publication types

  • Multicenter Study

MeSH terms

  • Clinical Protocols*
  • Health Plan Implementation
  • Humans
  • Medical Errors / prevention & control*
  • Pennsylvania
  • Risk Factors
  • Risk Management / methods
  • Risk Management / organization & administration*
  • Surgical Procedures, Operative / adverse effects*