Wrong Site Surgery Near Misses and Actual Occurrences

Assessments in which near misses were identified that did not advance to actual wrong site occurrences were significantly more likely to report compliance with patient identification and preoperative reconciliation protocols, accurate scheduling, notation of the surgical site on the consent form, participation of the surgeon in preoperative verification, participation of all surgical team members in the time out, time outs performed with the site marking visible after draping, and the surgeon explicitly empowering team members to speak up if concerned and acknowledging concerns when expressed. AORN J 90 (August 2009) 215-222. © AORN, Inc, 2009.