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.

Wrong-site surgery is considered a never event, and therefore hospitals have been required to implement protocols to prevent these errors. This systematic review did not identify any high-quality studies of successful methods to prevent wrong-site, wrong-patient, or wrong-procedure errors.