Minnesota Hospital Association

Quality & Patient Safety

June 22, 2010

Minnesota Patient Safety Alert: Accountability for Safe Site Key Principles - Senior Leadership Action Needed


Although Minnesota hospitals have been working diligently to eliminate wrong patient, wrong site and wrong procedure adverse events and have experienced success in specific areas, we are on target to experience higher numbers of wrong site procedures than ever before.

Examples of wrong site events: 

a)  Provider continues to have patients mark their own procedure site; wrong site surgery occurs. 

b)  Team does not see the mark, assumes site mark has been removed with surgical prep, does not stop the procedure to verify. 

c)  The patient is asked to confirm the operative leg; correct site is not verified with schedule or consent. 

d)  A time-out is not conducted for an interventional radiology procedure; procedure is performed on the wrong site.

Key issues:   

1)  The procedure site mark is not consistently being visualized immediately prior to the procedure start resulting in the procedure being conducted in the wrong location. 

In 38% of wrong site cases this year, the procedure site was correctly marked but no one on the team looked for the mark before the start of the procedure. 

 2)  The anesthesia procedure, such as a block, being conducted prior to a surgical procedure is not consistently being treated as a separate invasive procedure with separate site marking and a time-out conducted, resulting in the anesthesia procedure being administered at the incorrect site. 

In 30% of reported cases so far this year, an anesthesia procedure, e.g. block administered prior to a surgical procedure, was completed on the incorrect

3)  Site marking is not being consistently completed for interventional radiology procedures (interventional radiology procedures in which the procedure site is predetermined need to be site marked) resulting in procedures being performed at the incorrect site. 

20% of wrong site procedures last year occurred in interventional radiology.  

 4)  There are not clear expectations communicated that all surgeons and other providers performing procedures follow the Minnesota site marking and time-out recommendations.

78% of wrong site events this current year had one or more of the key site marking or time-out best practices not completed.

Call-to-Action for Senior Leadership

Key Best Practices - Visualizing Site Mark During Time-out

This is a step in the time-out process that should be clearly assigned (recommend scrub staff for OR).

If this step is not completed, providers and staff should know that it is an expectation that they speak up to “stop the line” until the mark has been visualized and communicated to the team.

Executive Leadership Actions:

Partnership with the Safe Site Surgeon and Operational Champion in your facility to:

  • Meet with the OR and procedure teams to discuss barriers and solutions.
  • Ask OR and procedure staff in areas such as interventional radiology and anesthesia to share observational audit data with you, which includes the percent to time that the site mark was visualized prior to procedure start.
  • Observe site marking and time-outs in action.

Key Best Practices - Anesthesia Procedures Preceding Surgical Procedure

Anesthesia procedures, such as blocks and injections, should be treated as separate invasive procedures. Site marking by the person performing the procedure, and a time-out by the procedure team, need to be completed for the anesthesia procedure. A second, separate site mark and time- out need to be conducted for the surgical procedure.

Executive Leadership Actions:

  • Meet with anesthesia team to discuss barriers and solutions.
  • Ask anesthesia staff to share observational audit data with you which includes the percent of time the anesthesia procedure site was marked and a time‐out conducted.    
  • Observe anesthesia procedure site marking and time‐outs in action.

Key Best Practices - Interventional Radiology 

All interventional radiology procedures in which the procedure site is pre-determined need to be site marked. Reports from radiologists estimate that approximately 95% of interventional radiology procedures are pre-determined (i.e., the procedure and laterality/location of the procedure to be performed are known).

A time-out needs to be conducted by the IR team prior to interventional radiology procedures regardless of whether or not site marking is needed.

Executive Leadership Actions:

  • Meet with interventional radiology teams to discuss barriers and solutions.
  • Ask interventional radiology staff to share observational audit data with you which includes the percent of time the procedure site was marked, when the site was pre‐determined, and a time‐out conducted.
  • Ask interventional radiology staff to demonstrate their site marking and time‐out process to you.
  • Observe interventional radiology site marking and time‐outs in action.

Key Best Practices - Following Minnesota Time-out and Site Marking Recommendations

The procedure site is marked by the practitioner who is ultimately accountable for the procedure; patients should not sign the site.   

All key steps of the time-out are completed by the procedure team for any invasive procedure.

Executive Leadership Actions:

  • Establish a formal, written “Hard Stop” (nothing moves forward) policy outlining: 

If these Safe Site actions are not followed, in any area of the hospital (e.g. OR, anesthesia, interventional radiology) staff and physicians should:

  • Be expected to call a “Hard Stop” (nothing moves forward) until these practices are completed; 
  • Know that they will be supported in stopping the line;
  • Have a clear channel of communication to follow if they are not supported in their immediate environment in calling for the “Hard Stop”; 
  • Know the organization’s expectations and consequences for not practicing these key Safe Site actions.
  • Share the Safe Site actions with your board, along with your hospital’s audit data related to site marking and the time‐out process in the operating room and areas outside the operating room.