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Wrong-Site Procedures: New Thoughts on How to Protect Your Patients

According to the Joint Commission Center for Transforming Healthcare, wrong site surgery occurs as often as 40 times per week in the U.S. All accredited organizations are required to use a preoperative verification process and surgical site marking process to help eliminate wrong site procedures. Goals, originally issued by the Joint Commission in 2003 to address “wrong site” surgeries, remain National Patient Safety Goals in 2015.

Yet, twelve years after the goals were first published, wrong site procedures still occur. A review of the National Patient Safety Goals to eliminate wrong site procedures reflects these recommendations:

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  • Use a “time out” process before an invasive procedure – even in the office setting.
  • Implement a process to mark the surgical site that involves the patient/family.

We recommend the following real-life scenarios and practices to augment existing safety protocols in facilities and/or hospitals:

  • Separate procedures on same patient require separate “time outs”
    • Situation: A facility did not perform a “time out” for regional nerve block by anesthesiologist in preparation for rotator cuff surgery. The “time out” was erroneously perceived to be necessary for only the orthopedic surgery procedure. The anesthesiologist blocked the wrong shoulder based on reliance of his memory of the chart.
    • Solution: The facility’s protocol now mandates separate “time out” confirmations for both regional block insertion and surgical incision procedures.
  • Site marking must be observable after prepping and draping
    • Situation: Orthopedic surgeon properly marked multiple sites on the palm and wrist of same hand for multiple procedures on the patient. However, surgery was performed on the wrong finger. The marking on the correct digit was hidden after patient’s palm was prepped and draped.
    • Solution: The facility’s protocol now requires the marking to remain observable despite prepping and draping. Thus, for finger surgery, the tip of the finger for surgery (not only the palm) must be marked and left exposed. Thus “X marks the spot” only if the marking can still be seen after prepping and draping.
  • Marking must be observable when patient is repositioned
    • Situation: Site was marked on anterior leg prior to knee replacement surgery. Patient was turned to the prone position before  the anesthesiologist’s arrival. Thus, the site marking was not seen by the anesthesiologist. The anesthesiologist relied on confirmation from the patient that “this is the correct leg.” However, patient had already received a sedative and answered incorrectly, resulting in the anesthesiologist blocking the wrong leg.
    • Solution: If possible, patient involvement in “time out” now occurs before any sedation is administered and is never the exclusive method of confirmation. The new protocol also requires royal blue tape to be placed circumferentially around a limb to be blocked, in addition to the marking of site by the physician(s).
    • This eliminates confusion when patient has been re-positioned. The tape is visible from all angles, and requires no adjustment during patient repositioning. This practice has been dubbed “No Blue, No Block” by J. Eric Greensmith, MD, PhD of Penn State Hershey Medical Center.


Author Catherine Miller, RN, JD, is a Risk Management & Patient Safety Specialist at the Cooperative of American Physicians, Inc. (CAP) in its CAPAssurance, A Risk Purchasing Group, program that offers hospitals, large medical groups, and other health care facilities access to top-rated liability protection and risk management services.


If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.