Wrong-site, wrong-procedure, or wrong-patient adverse events are completely preventable and should never happen. Yet these devastating errors continue to plague health care.
In fact, the Joint Commission's Sentinel Event Database receives approximately 9 voluntary reports per month of wrong-site adverse events. This rate has increased since the implementation of the Universal Protocol for Preventing Wrong-Site, Wrong-Procedure and Wrong-Person Surgery in July 2004. The Joint Commission reviewed 83 cases of wrong-site surgery in 2005. The top 3 root causes were communication, 70%; procedural compliance, 64%; and leadership, 46%. Previously, the top 3 root causes from 1995 to 2004 were communication, 78%; orientation and training, 45%; and procedural compliance, 30%.