Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.