Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.