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Wrong Site Surgeries

According to the best available estimate, there are approximately 40 to 60 wrong site surgeries per week in the United States. Research has shown that, often, there is usually no one root cause of failure. Rather, such events are frequently the result of a cascade of small errors that are able to penetrate organizational defenses. Because of this, the Center joined forces with the Lifespan Health System in Rhode Island to initiate the Safe Surgery project in July 2009. The goal was to improve the safeguards to prevent wrong site, wrong side, and wrong patient surgical procedures by helping organizations identify, measure, and reduce risks across their surgical process areas including scheduling, pre-operative, and operating room areas. In 2010, the Safe Surgery project was later piloted with four additional hospitals and three ambulatory surgical centers to validate the methodology and targeted solutions.

Project Team

The project teams utilized Robust Process Improvement® (RPI®) methods and tools in the development of their solutions. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates specific tools and methods from Lean Six Sigma and change management methodologies. Using RPI, the project teams discovered the contributing factors that led to a risks in the surgical scheduling, pre-op, and operating room processes. The team then developed proven-effective solutions to address these factors.

Participating Hospitals
Anmed Health Medical Center, South Carolina
Center for Health Ambulatory Surgery Center, Illinois
Holy Spirit Hospital, Pennsylvania
LaVeta Surgical Center, California
Lifespan Health System, Rhode Island
Seven Hills Surgery Center, Nevada
The Mount Sinai Medical Center, New York
Thomas Jefferson University Hospital, Philadelphia

Pilot Team
Algonquin Road Surgery Center, LLC, Illinois
Holy Spirit Hospital, Pennsylvania
Lafayette Surgical Hospital, Louisiana
The Urology Group, Ohio

Project Results

The original participating organizations were able to reduce the number of cases with risks by:

  • 46% in the scheduling area.
  • 63% in the pre-op area.
  • 51% in the operating room area.

The organizations that participated in the Center’s project identified 29 main causes of wrong site surgeries that occurred during scheduling, in pre-op or pre-op holding, in the operating room, or which stemmed from the organizational culture.

Our Safe Surgery Targeted Solutions Tool

The Center’s Safe Surgery Targeted Solutions Tool® (TST®) is an innovative web-based application designed to help health care organizations assess their scheduling, pre-operative and operating room processes, determine the risks that lead to wrong site surgeries, and implement evidence-based practices that promote safe surgery.