Wrong–Site Surgery: Does That Really Happen?



It’s going to be a busy day in the operating room (OR). The orthopedic group has a full caseload, neurosurgery is performing four spinal cases. The new general surgeon has two gall bladder cases and anesthesia is doing a half-dozen pain management injections in the block room. The first case of the day has been delayed, as an auto accident on the freeway has the surgeon stuck in traffic.

The preoperative care unit is filled with anxious patients and their significant others. Transport personnel are arriving with patients from the nursing units as staff are busy starting intravenous lines and initiating preop orders. All in a coordinated effort, preparing for surgical procedures.

What could possibly go wrong?

Author Biography

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.


Yonash R, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. Patient Saf. 2020;2(4), 24–39. https://doi.org/10.33940/data/2020.12.2

The Joint Commission. 2021 National Hospital Patient Safety Goals. TJC website. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/simplified-2021-hap-npsg-goals-final-11420.pdf. Published November 4, 2020. Accessed February 11, 2022.

The Joint Commission. The Universal Protocol. TJC website. https://www.jointcommission.org/standards/universal-protocol/. Accessed February 11, 2022.

Patient Safety Authority. Principles for Reliable Performance of Correct-Site Surgery. PSA website. http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/principles.aspx. Published September 2009. Accessed November 1, 2010.

Yonash R, Taylor M. Online Supplement to “Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities.” Patient Saf. 2020;2(4), i-x. https://doi.org/10.33940/supplement/2020.12.10

Clarke JR. Quarterly Update on Preventing Wrong-Site Surgery. Pa Patient Saf Advis. 2012;9(1):28–34. http://patientsafety.pa.gov/ADVISORIES/Pages/201203_28.aspx

Patient Safety Authority. Monitoring of Preoperative Information from Surgeon’s Office Available at First Encounter (Preadmission Testing or Preoperative Admission). PSA website. http://patientsafety.pa.gov/pst/Pages/Wrong%20Site%20Surgery/office_monitor.aspx. Published 2012. Accessed February 11, 2022.

Arnold TV. Quarterly Update on Wrong-Site Surgery: Eleven Years of Data Collection and Analysis. Pa Patient Saf Advis. 2015;12(3):119–20.

3 Medical personnel standing in front of an OR, with masks on, and text bubbles with check marks, next to the people.



How to Cite

Yonash, R. A. (2022). Wrong–Site Surgery: Does That Really Happen?. Patient Safety, 4(1), 60–63. Retrieved from https://patientsafetyj.com/index.php/patientsaf/article/view/wss-perspective
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