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Arch Surg. 2010 Oct;145(10):978-84. doi: 10.1001/archsurg.2010.185.

Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.

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  • 1Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 80204, USA.



To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol.


Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori.




Database contained 27 370 physician self-reported adverse occurrences.


Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes.


A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.


These data reveal a persisting high frequency of surgical "never events." Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.

[PubMed - indexed for MEDLINE]
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