Getting surgery right.

Objective: We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).

Methods: We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006.

Results: Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion.