Minnesota Hospital Association

Patient Safety

Preventing Wrong-Site Surgery and Procedures

In the years following the implementation of the adverse health event reporting law, wrong-site surgery and procedures (the wrong procedure being performed, or a procedure being performed on the wrong body part or patient) were on the rise.

An analysis of the data and root cause analyses showed that these events were primarily a breakdown in following basic best practices. In response, in 2007, Minnesota Hospital Association initiated the Call to Action framework for SAFE SITE. Like MHA’s other Calls to Action, it provides a road map of best clinical practices and a tool kit to implement the road map recommendations. Currently 120 hospitals and outpatient surgery centers are participating. The SAFE SITE road map builds on the Institute for Clinical Systems Improvement (ICSI) Safe Site Surgical Protocol. The initial efforts were focused on the operating room, but have expanded to include anesthesia, radiology, CV lab, endoscopy, bedside procedures, the emergency department, clinic settings and radiation therapy.

call to action logoDownload the Road Map for Safe Procedures: Procedural Safety Across the Board.


To bring even greater attention to the issue, MHA, the Minnesota Department of Health, the Minnesota Medical Association, the Minnesota Medical Group Management Association and MMIC Group partnered to form the Minnesota Safe Surgery Coalition, which aims to eliminate wrong surgeries and procedures. The Minnesota Organization of Leaders in Nursing (MOLN), the Minnesota Ambulatory Surgery Center Association (MNASCA) and the Minnesota Hospital Association Physician Leadership Council (PLC) have also pledged their support for the coalition.

time out logoThe initial efforts of the Minnesota Safe Surgery Coalition are focused on the Time Out Campaign, which seeks to eliminate wrong site events through administration, physicians and front-line staff joining together to hold each other accountable for conducting robust, effective time-outs for every patient, every invasive procedure, every time.

Tool Kit for Hospital Staff

The tool kit provides tools that hospitals can use to implement the road map recommendations in their facilities. Hospitals may copy, translate, distribute and present the following SAFE SITE Tool Kit items as long as you reference the Minnesota Hospital Association as the source of this material. If the tool is hospital-specific, please also cite the hospital as a source. Dates listed refer to the date the tool was posted on the website. Product examples within this tool kit are not inclusive nor intended as endorsement of a specific product. 

Safe site team

Access to information

Facility expectations

Educate staff and parents

Sign site with initials

Informed consent and verification


Effective communication

Data Submission

Road Map Data Submission and Tool Kit Website

Requirements of SAFE SITE initiative participants:

  • Completion of baseline road map data submission and quarterly updates
  • Implementation of the SAFE SITE road map components
  • Share learnings with others through conference calls, listserv and other sharing opportunities.