Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

The Joint Commission requires time outs prior to surgical incision. This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.

According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.