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Friday 7:14 CST, October 31, 2014

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Sentinel Event Alert, Issue 6: Lessons Learned: Wrong Site Surgery

August 28, 1998

Sentinel Event Alert Issue 6Since the Joint Commission's Sentinel Event Policy was first introduced two years ago, the Accreditation Committee of the Board of Commissioners has reviewed 15 cases related to surgery at the wrong site (e.g. left leg instead of right. A root cause analysis was completed for each of the events reviewed. Wrong site surgery was most common during orthopedic procedures, followed by urologic procedures and neurosurgical procedures.


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