Knowledge Bank

Wrong-site surgery events are a significant problem for surgical departments, causing devastating physical and psychological harm to patients. Additionally, there is a negative impact to the financial performance and reputation of the facility (Collins, Newhouse, Porter, & Talsma, 2014). These preventable events continue to occur despite initiatives by organizations such as Joint Commission and the World Health Organization (Joint Commission, 2019; World Health Organization, 2019). The purpose of this quality improvement project was to implement an evidenced based, standardized wrong-site surgery protocol and Safe Surgical Checklist with the intent of eliminating wrong site surgery events. Project implementation occurred at one Ambulatory Surgery Center (ASC) during a three-month period. By focusing on each phase of the perioperative period through a standardized process, wrong-site surgery events would be eliminated and patient outcomes optimized.
The literature revealed that barriers to the elimination of wrong-site surgery events included a lack of team engagement and a lack of process oversight. Evidence supported a standardized approach and the use of a Safe Surgical Checklist (Borchard, Schwappach, Barbir, & Bezzola, 2012). This project incorporated both strategies, including a revised Surgical Checklist and an observational audit of compliance.
Results showed zero wrong-site surgery events during the implementation period, compared to only one event during the same three months of 2019. Audits of staff compliance with the new process showed improvement over time which demonstrated clinical significance. Re-education and staff feedback during the project was credited with helping to improve performance.