Circulation 36,825 • Volume 18, No. 2 • Summer 2003

Wrong Site Surgery Summit Plans Universal Protocol

Joint Commission Resources, Inc., a subsidiary of JCAHO, has announced the results of the proceedings of a recent Wrong Site Surgery Summit, which was held on May 9, 2003. The Summit was co-sponsored by JCAHO and its corporate members. More than 50 participants discussed root causes of wrong site surgery and addressed potential barriers to prevention and elimination of wrong site surgery. Five key areas were identified including:

  • Preoperative verification
  • A time-out prior to beginning a procedure
  • Surgical site marking
  • Special situations and settings outside of the operating room
  • Physician buy-in

Several conclusions were reached which included

  • Active involvement of everyone on the surgical team is needed.
  • Multiple redundant strategies are required, including a preoperative verification process, site marking, a time-out to verify the correct patient, the correct site, and the correct procedure.
  • If the verification process does not occur, the procedure should not take place.
  • Patient involvement is essential in the verification process.
  • Cases with left/right distinction or multiple structures (fingers, toes) or levels should receive particular focus.

Summit participants agreed that a universal protocol should be adopted that is both standardized and consistent (yet flexible enough to allow for appropriate adaptation necessitated by special circumstances). A plan was developed to draft such a universal protocol, solicit feedback and input, revise the draft, and have a finalized version presented to the JCAHO’s Board of Commissioners.

It has also been determined that organizations will no longer be required to mark the site for certain types of procedures such as midline sternotomies, cesarean sections, and interventional procedures without a predetermined insertion site, such as cardiac catheterization.

Joint Commission Resources, Inc., will also sponsor a wrong site surgery seminar in the Fall of 2003, and further information is available on their website at The APSF Newsletter solicits thoughts and input from its readership regarding the processes and personnel ensuring verification of the correct patient, surgery, surgical site, and side.