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The perioperative setting is a high-risk environment. This continuing education model discusses safety threats and evidence-based best practices to deliver nursing care in perioperative settings and promote a culture of safety.

UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.

Wrong-side procedures still occur at alarming rates, particularly outside of the operating room. This study exposed medical students to various types of distractions and measured their ability to distinguish a person's left from right side from different perspectives. Cognitive distractions had a bigger negative impact than ambient ward noise on the students' performance.

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.

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.

Excisional skin cancer surgery is a common procedure often performed many days after an initial biopsy by a different physician, making it particularly vulnerable to wrong-site surgery. This study provides a range of consensus recommendations for medical professionals and patients to reduce such risks.

By tracking improper surgical bookings and observing time-out procedures, this study measured near misses for wrong-site surgery and provided education about correct procedures when they encountered errors. After this education, surgical booking and time-out procedures improved.

This review discusses wrong site surgery in otolaryngology, along with preventive strategies such as the Universal Protocol, the WHO checklist, and radiofrequency identification tags.

More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.

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.

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.

Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.

Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.