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Zero Tolerance for Wrong-site Surgery

Any number of factors, from a lack of adequate pre-surgical planning to a failure to follow proper procedures, can result in a wrong-site surgery. Let's review the best practices for avoiding this devastating error.

Verify, mark, then verify again
The majority of wrong-site surgeries are caused by "a breakdown in communication between surgical team members and the patient and family," the Joint Commission stated in a December 2001 Sentinel Event Alert. To catch wrong-site errors before it's too late, you must develop clear, step-by-step procedures for verifying the correct surgical site both pre-operatively and intraoperatively. The Joint Commission's Universal Protocol, which provides specific recommendations for preventing wrong-site surgery, has been supported by more than 40 professional medical organizations. Based on that protocol, here's what we advise.

  • In pre-op. A system of checks and balances is the best defense against wrong-site surgery. Before the patient enters the OR, at least three different members of the surgical team should have verified the patient's identity and the surgical site. First, a pre-op staff nurse identifies the patient by name and at least one other piece of information, such as date of birth or Social Security number. The RN then verifies the procedure and the site/side on which it will be performed, both with the patient and with the operative record. Have the patient state the surgical site verbally and point to it while the nurse is there.

Next, it's the surgeon's turn to mark the surgical site while the patient is still awake and able to verify it. Using a permanent marker, the surgeon makes an unambiguous mark on the operative site, or the holding nurse draws a line on the correct site, and the surgeon then puts his mark on that line. The mark should be the surgeon's initials or the word "yes"; the letter X is not acceptable, since it's unclear whether it means "X marks the spot" or "avoid this side/site." The mark on the operative site should also be visible during prepping and draping of the patient. Before the patient is brought into the OR, the anesthesia personnel and circulator verify the site one more time.

  • In the OR. Again, communication among all members of the surgical team is crucial to catching mistakes. Here, the surgeon begins by confirming radiographs by the patient's name and the surgical site. Next, one of the nurses confirms the following: patient consent, surgical procedure, patient's position, and the surgical site and side as indicated by the operative record and the area marked on the patient.

The final step before the procedure can begin is the time out. All team members must stop what they're doing and verbally verify their agreement that the following information is correct: patient's name; procedure being performed; the surgeon doing the procedure; the site/side that will be operated on; radiographs; and any implants or special equipment needed. Designate one team member to document the names of all personnel present for the time out and verify that they've all participated. If there's no confusion about the patient's identity or the nature of the procedure, the team may then proceed.

Case closed
Wrong-site surgery is just not tolerated — not by patients, their families, healthcare providers or malpractice lawyers. The causes of wrong-site surgery — miscommunication, short cuts, carelessness, failure to follow procedure — shouldn't be tolerated either. Conduct regular audits of your surgical team using the Correct-site Surgery Audit Tool on page 36 to make sure everyone's doing their part to prevent this error. Continue to audit your staff periodically until you've got 100-percent compliance. OSM

Correct-site Surgery Audit Tool


Yes, No, N/A



  • RN identifies patient using two identifiers (for example, name, date of birth, SSN).
  • RN verifies the procedure and site/side with the operative record and patient.
  • Patient states and points to the site/side where surgery is to be performed.
  • Surgeon uses a permanent marker to sign the surgical area with an unambiguous and visible mark.
  • Anesthesia personnel and circulator verify the site before bringing the patient into the OR.

Operating Room

  • Surgeon confirms radiographs by patient's name and surgical site.
  • RN confirms patient consent, surgical procedure, position and site/side, noting the area marked on the patient.
  • Surgical team checks availability of any implants or special equipment required for the procedure.
  • Before start of procedure, stop for time out to verify:
    a. correct patient
    b. correct procedure
    c. correct surgeon
    d. correct site/side
    e. correct radiographs
    f. correct implants/special equipment
  • Entire team verbally verifies their agreement of the above.
  • RN documents the names of the team members present for the time out.

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