In 2000, a report was published that focused on the high rate of medical errors in the United States. Wrong site surgery is defined as any surgery performed on the wrong site or patient or performing the wrong procedure. Since January 1995, 197 wrong site surgeries have been reported through the Joint Commission on Accreditation of Healthcare Organizations sentinel event reporting system. Incidents of wrong site surgery should not happen. The perioperative health care team composed of nurses, physicians, anesthesia care providers, unlicensed assistive personnel, admission workers, clerks, and other ancillary staff members must make patient safety an uncompromising goal. This article describes the problem and identifies potential causes for incidences of wrong site surgery. The article also describes steps to act on AORNs patient safety initiative, which includes five suggestions for the development of any surgical site verification policy. Using these suggestions as guidelines for developing a policy and procedure will help decrease the risk of avoidable errors.