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According to The Joint Commission (JC), wrong-site surgery (WSS) is the most common type of sentinel event at 13.5%. Wrong-site surgery was reported 867 times out of 6428 sentinel events that have occurred since 1995 (2009). The Joint Commission describes a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury…events are called ‘sentinel’ because they signal the need for immediate investigation and response (2009)”. Wrong-site surgery is an all-inclusive term to encompass any surgery done on the wrong-side, wrong patient, wrong site/organ/extremity/location, or the wrong procedure being done. Although WSS is an uncommon event, even considered a rare happening, the National Quality Form (2006) refers to WSS as a “never event”. “Wrong-site surgery is perceived as a medical error that should never happen, not a medical risk that a patient should accept…(Clarke 2007) ”. “A zero tolerance policy is the only standard that can be ethically justified by providers or accepted by patients and the public (Sieden 2006).” Since 2003, after hosting a Wrong-Site Surgery Summit, which included consulting fifty-one professional health care associations and organizations, i.e. American Medical Association, American Hospital Association, The JC requires that the Universal Protocol (UP) to be implemented in all surgery departments at accredited hospitals, ambulatory surgery centers, and office-based surgery centers or facilities. The UP has three components: a pre-procedure patient verification process, surgical site marking, and performing a “time-out” or pause directly before starting an invasive procedure. The JC requires the UP but does not indicate exactly how to implement it; it is up to the facility to interpret and implement the UP as it sees fit.


Clarke, J., R., Johnson, & J., Finley, E., D., (2007). Getting surgery right. Annals of Surgery 246 (3). 395-405.
Seiden, S., & C., Barach, P. (2006). Wrong-side/wronge-site, wrong-procedure, and wrong-patient adverse events. Are they preventable? Archives of Surgery 141:931-939
National Quality Forum (2006). Serious reportable events in healthcare: A consensus report. Washington: National Quality Forum.The Joint Commission (2009). Sentinel event statistics as of september 30, 2009 Retrieved from on October 28, 2009
The Joint Commission (2009). Universal protocol. Facts about the universal protocol. Retrieved from on September 26, 2009
The Joint Commission (1998). Sentinel event alert. Lessons learned: wrong site surgery. Retrieved from on August 8, 2009.