Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities





wrong patient, wrong procedure, wrong side, surgical error, interventional radiology, clinician specialty, surgical procedure, WSPE, wrong-site surgery


visual abstract

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

Author Biographies

Robert A. Yonash, RN, Patient Safety Authority

Robert A. Yonash (ryonash@pa.gov), a registered nurse, has been with the Patient Safety Authority (PSA) since 2009 as the patient safety liaison for the Southwest region of Pennsylvania. He works with medical facilities to eliminate medical errors and has undertaken several projects, including a joint initiative with the Pennsylvania Society of Anesthesiologists on wrong-site blocks and serving as a Core Team Lead for the PSA’s Center of Excellence for Improving Diagnosis. Yonash is a member of the American Society of Professionals in Patient Safety and has attained certification as a Certified Professional in Patient Safety (CPPS) and a Lean Six Sigma Healthcare Green Belt. He is also a master trainer in TeamSTEPPS.

Matthew A. Taylor, PhD, Patient Safety Authority

Matthew A. Taylor (MattTaylor@pa.gov) is a patient safety analyst for the Patient Safety Authority (PSA), where he conducts research; uses data to identify patient safety concerns and trends; and develops solutions to prevent recurrence, as well as tools and materials to help facilities and clinicians improve patient safety. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention (CDC) and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.


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man lying on gurney for surgery with feet hanging



How to Cite

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



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