Make All Surgeries the Right Ones

How to prevent surgeries performed on the wrong site, procedure or patient — or with the wrong implant.

Nearly half of the 1,575 sentinel events reported to The Joint Commission (TJC) last year were falls. Tied for second were wrong surgeries: There were 127 incidents, or 8% of all reported events.

Procedures performed on the wrong side of the patient, the wrong procedure on a patient, the wrong patient entirely or surgeries using the wrong implant were the highest category of sentinel reports to TJC from ambulatory settings, however. Fourteen of the 37 incidents from ASCs, about 38%, were wrong surgeries.

The 127 reports marked the third year in a row that wrong-surgery incidents increased. There were 89 reports in 2022 and 112 in 2023.

Sixty-eight percent of the reports were wrong-site surgeries. Twelve percent were wrong-patient reports, while 11% were wrong-procedure incidents and 9% were wrong-implant cases.

“Nerve blocks or injections for pain management comprised 33% of laterality-related wrong-site surgeries followed by urologic procedures such as ureteroscopy and stent placement (13%),” states the TJC’s Sentinel Event Data 2024 Annual Review. “Procedures on the incorrect tooth, such as wrong tooth extraction or restoration, comprised 14% of wrong-site surgeries. Spinal surgeries were associated with seven of nine sentinel event reports related to wrong-level surgeries and placement of the wrong lens comprised 73% of wrong implants.

“Of reported wrong surgery sentinel events, 51% resulted in severe harm that was temporary and 36% in severe harm that was permanent. No deaths were attributed to wrong-surgery sentinel events.”

The report lists the following leading contributors to the wrong surgeries: policies and procedures not followed or adhered to; time outs not performed or incomplete; lack of shared understanding or mental model across the care team; task fixation or preoccupation limiting situational awareness; insufficient provider competency to recognize anatomical or other irregularities; a lack of redundancy in processes or inadequate use of them; inadequate communication of critical information among staff; suboptimal communication between handoffs or other transitions of care; task saturation/multitasking; and incomplete information in electronic health records.

Better handoff communications

To reduce the potential for wrong-site and other sentinel events, Monica Harrelson, MSN, CNOR, CNL; Kayleigh Kautz, BSN, CNOR, CNAMB; and Francia Marshall, BSc, BSN, RN-BC, from Houston Methodist Hospital - Texas Medical Center sought to improve nurses’ communication during handoffs and to better document those transfers afterward.

Historically, there had been no standardized in-person bedside handoff process between the preoperative and intraoperative nursing departments in parts of Houston Methodist, “directly leading to miscommunication between staff, adverse events, near misses and unsafe conditions that were captured in the Transparency and Accountability in Patient Safety (TAPS) program tool for event reporting. A closed record chart review additionally revealed incomplete nursing documentation of handoffs before patients enter the operating room.”

In April 2023, 60% of handoffs in the areas studied were documented and 40% were not, according to a poster presentation at the 2025 AORN Global Surgical Conference & Expo in Boston. Ms. Harrelson, Ms. Kautz and Ms. Marshall sought to increase documentation to 80% by February 2024.

A new handoff process workflow was created to reach that goal: At the conclusion of the morning huddle, the OR nurse goes to the OR to complete chart verification in the EMR; the OR nurse identifies the name of the pre-op nurse, then calls them to let them know it’s time to meet at the bedside, where the nurses open the Handoff Report Tab in the EMR and perform the documented handoff. The average compliance rate rose to 93% by February 2024.

Help is available

The Joint Commission’s Universal Protocol includes pre-procedure verification, the surgeon marking the procedure site and a thorough and intentional time out. The World Health Organization has a structured surgical safety checklist to establish a dialogue around three key phases in surgical care — before the induction of anesthesia, before the incision and before the patient leaves the operating room. AORN combined elements from TJC’s and WHO’s documents to create a comprehensive checklist that discusses what to do during four phases of care: the pre-procedural check-in, sign-in, time out and sign-out.

AORN says the following evidence-based practices can be used by surgical teams to reduce adverse events: team members addressing each other by name; have staffing resources that are sufficient; eliminate hierarchical barriers; and have familiarity among team members.

When assessing the quality of time outs, AORN suggests the following: standardize the time out process to make it more effective; make sure the pause involves all members of the perioperative team; designate one team member to call for the time out; stop all unnecessary activities and conversations when the time out is called; and discuss any concerns about patient safety or the upcoming procedure during the time out. OSM