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Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.
Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Ragusa PS, Bitterman A, Auerbach B, et al. Orthopedics. 2016;39:e307-10.
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.
Collins SJ, Newhouse R, Porter J, et al. AORN J. 2014;100:65-79.e5.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.
Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
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.
Gauss T, Merckx P, Brasher C, et al. Langenbecks Arch Surg. 2013;398:277-85.
Deviations from the previously agreed upon perioperative care plan were associated with an increased risk of adverse events during surgery. Unplanned changes in surgical procedures have been previously associated with higher risk for retained surgical instruments.
Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-2.
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.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
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.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-73.
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.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
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.
Duthie EA. J Patient Saf. 2010;6:108-114.
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.
Devine J, Chutkan N, Norvell DC, et al. Spine (Phila Pa 1976). 2010;35:S28-36.
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.
Dunn D. J Perianesth Nurs. 2006;21:317-28; quiz 329-31.
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.
Mitchell P, Nicholson CL, Jenkins A. Acta Neurochir (Wien). 2006;148:1289-92; discussion 1292.
The authors interviewed surgeons involved in wrong-site incidents and found that the errors of omission were primarily due to distractions in the operating environment.