1103 - Ensuring Correct Site Surgery: Pennsylvania's Evidenced Based Principles

Learning Outcome: Eighty percent (80%) of learners will be able to recognize how wrong- site surgery (WSS) events occur, identify factors that contribute to WSS events, describe evidence-based principles to prevent WSS, and explain how implementation and compliance of best practices can eliminate a WSS.

Overview/Abstract: Wrong-site surgery (WSS) is never an event¹- yet it occurs at an alarming rate. Despite the development of well-established prevention guidelines by organizations such as the Joint Commission (TJC)² and the World Health Organization³, these events continue to pose significant risks to patient safety. TJC noted WSS as the second highest category of sentinel events reported in 2023.⁴ In Pennsylvania alone, approximately 1–1.5 cases of WSS are reported each week.⁵
Since 2004, the Patient Safety Authority (PSA) has collected and analyzed data related to WSS through the state’s mandatory reporting system, the Pennsylvania Patient Safety Reporting System (PA-PSRS).⁶ Findings from this data have not only identified gaps that must be addressed to eliminate WSS but also have led to the creation of actionable strategies that healthcare facilities can implement to reduce WSS events and safeguard patient safety.⁷
In 2022, the PSA worked in conjunction with the Pennsylvania Department of Health to develop the "Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks”- a bold step towards strengthening existing protocols. While not a state law, the PSA believes these recommendations, if followed, will reduce the number of WSSs and wrong-site nerve blocks in all Pennsylvania facilities.⁶'⁸
Join us as we take a fresh, proactive approach to ending WSS for good. Awareness of the threat is no longer enough- now is the time for action.

Description of Current State: Wrong-site surgery (WSS) is a surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.⁹ WSS continues to happen in Pennsylvania and across the United States. Pennsylvania sees approximately 1-1.5 WSS per week. The Joint Commission noted WSS as the second highest category of sentinel events reported in 2023. Contributing factors have been identified through analysis of Pennsylvania Patient Safety Reporting System (PA-PSRS) data and reported by Patient Safety Authority (PSA). The Authority continues to support WSS prevention guidelines. The Authority conducted a survey of patient safety professionals in the state of Pennsylvania to identify barriers related to the implementation of prevention guidelines. Barriers largely fell into two categories: noncompliance (including complacency, distractions and lack of buy-in) and time constraints.⁶

Description of Desired/Achievable State: By the end of this educational activity, learners will be equipped to recognize the ongoing risk of WSS events and its impact on patient safety; identify the key contributing factors to WSS events; apply evidence-based best practices designed to prevent WSS; implement and sustain these best practices within their facility to drive compliance and eliminate WSS events.

Audience Engagement: We will use story- telling, polling questions, case studies, and offer a Question and Answer period to engage and re-engage the audience during this activity.

Additional Information: We are currently writing a manuscript for the PSA's journal, "Patient Safety". The topic of the manuscript will be wrong-site surgery with a review of the data from 2015-2024 and a study of the variables associated with these events.

Content/Topics: I. Introduction/Setting the Stage for Safety
a. Brief overview of PSA and its role in patient safety
b. Learning model
II. Insights and Realities
a. Eye-opening statistics: PA-PSRS data and trends 2015-2024
b. Define wrong site surgery
c. Impact on patient outcomes and on team
III. Uncovering Common Contributing Factors
a. Real-life scenarios: How errors happen
b. Inaccurate information and miscommunication
c. Risks of skipped verification
d. Patient positioning
e. Time Out not completed
f. Other common factors
IV. Implementing Best Practices
a. Preoperative verification and reconciliation: Ensuring accuracy from the start
b. Site marking done right: Techniques and challenges
c. Power of the Time Out: Why it matters and how to make it effective
d. Intraoperative Verification: Real time vigilance when applicable
e. Accountability in Action: Promoting a culture of safety
V. Case Studies: Learning from real events
a. Analysis of actual cases: What went wrong and how to prevent it
VI. PSA Resources
VII. Interactive Question and Answer

References: 1. Centers for Medicare & Medicaid Services. (2006, May 18). ELIMINATING SERIOUS, PREVENTABLE, AND COSTLY MEDICAL ERRORS - NEVER EVENTS | CMS. Cms.gov. https://www.cms.gov/newsroom/fact-sheets/eliminating-serious-preventable-and-costly-medical-errors-never-events
2. The Joint Commission. (2024). National patient safety goals effective January 2025 for thehospitalprogram.https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2025/hap-npsg-chapter-2025.pdf
3. World Health Organisation. (2009). WHO Guidelines for Safe Surgery 2009 Safe Surgery Saves Lives. https://iris.who.int/bitstream/handle/10665/44185/9789241598552_eng.pdf?sequence=1
4. Sentinel Event Data 2023 Annual Review. (2024). In The Joint Commission (pp. 1–9). https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/2024/2024_sentinel-event-_annual-review_published-2024.pdf. In 1996, The Joint Commission created a Sentinel Event Policy to help healthcare organizations that experience serious adverse events improve safety. The Joint Commission’s Office of Quality and Patient Safety assists healthcare organizations in conducting comprehensive systemic analyses to learn from these sentinel events. Since that time, The Joint Commission has maintained an associated Sentinel Event Database with de-identified and aggregate data.
5. Yonash, R., & Taylor, M. (2020). Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. Patient Safety, 2(4), 24–39. https://doi.org/10.33940/data/2020.12.2
6. Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks. (2022). In The Pennsylvania Code and Bulletin. Commonwealth of Pennsylvania. https://www.pacodeandbulletin.gov/Display/pabull?file=/secure/pabulletin/data/vol52/52-12/448.html. This document outlines final recommendations to hospitals, ambulatory surgery facilities, birthing centers and abortion facilities in this Commonwealth to ensure the correct procedure is performed on the correct site, side and patient.
7. Patient, P. (2024). Wrong-Site Surgery Patient Safety Topic. Pa.gov. https://patientsafety.pa.gov/pst/Pages/Wrong%20Site%20Surgery/hm.aspx?t=overview
8. Act No. 13 of 2002 MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR (MCARE) ACT, P.L. 154, No. 13 Cl. 40 (2002). https://www.palegis.us/statutes/unconsolidated/law-information?sessYr=2002&sessInd=0&actNum=13. Reforming the law on medical professional liability; providing for patient safety and reporting; establishing the Patient Safety Authority and the Patient Safety Trust Fund; abrogating regulations; providing for medical professional liability informed consent, damages, expert qualifications, limitations of actions and medical records; establishing the Interbranch Commission on Venue; providing for medical professional liability insurance; establishing the Medical Care Availability and Reduction of Error Fund; providing for medical professional liability claims; establishing the Joint Underwriting Association; regulating medical professional liability insurance; providing for medical licensure regulation; providing for administration; imposing penalties; and making repeals.
9. NQF: List of SREs. (n.d.). Www.qualityforum.org. https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx