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After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

This literature analysis identified elements that led to successful implementation of the Joint Commission's Universal Protocol to prevent wrong-site surgeries.

This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.

Although wrong-site surgeries are rare, they have devastating consequences for patients and are often a harbinger of serious safety problems within an institution. The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery to ensure that all operating room personnel are familiar with the patient, the procedure, their role, and how to respond to complications. In this study, operating room personnel were surveyed regarding their perception of the risk of wrong-site surgery before and after institution of timeouts. Respondents felt teamwork improved and the overall risk for wrong-site surgery decreased after implementing the protocol. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses the factors contributing to a near-miss wrong-site surgery.