The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

In this study, cataract surgeons were asked to identify the correct eye for surgery when given the patient's name only, and again while looking at the patient's face. The surgeons answered incorrectly approximately a quarter of the time, arguing for the importance of preoperative time outs to avoid wrong-site surgery.

Describing a case of duplicate surgical site markings on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site surgery.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.

A 6-item checklist was successfully implemented and used in more than 99% of neurosurgical cases over an 8-year period. The institution did not experience any wrong-site surgeries during that time.

This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.

This study examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.

This systematic review of methods to prevent wrong-site surgery discusses the limitations of current preventive strategies, and proposes specific interventions to prevent wrong-site spinal surgery.

This article highlights the discussion at a joint symposium between Canadian and American orthopedic associations. The authors discuss the state of patient safety, wrong-site surgery, and future areas for improvement initiatives.

This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.

The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.

The author reviews the epidemiology of surgical adverse events from major epidemiologic studies and discusses the need for a systems approach to preventing wrong-site surgery with particular emphasis on spinal surgery.