Background Wrong-site surgery (WSS) remains a significant and avoidable medical error, persisting despite decades of national and international efforts to prevent it. Pennsylvania is one of the few large governments or entities that mandates reporting of patient safety events ranging from near misses to serious events. Methods We used the Pennsylvania Patient Safety Reporting System database to study a 10-year period (2015–2024) of wrong-site surgery events at hospitals and ambulatory surgical facilities. We reviewed and analyzed event reports for the following clinically related variables: facility type, hospital procedure location, hospital bed size, error type, clinician specialty, body region, specific body part, procedure group, and specific procedure. Results We identified 664 WSS events that occurred in Pennsylvania during the 10-year period of 2015–2024. The events were reported by 237 hospitals and ambulatory surgical facilities. The 16 visuals presented in this study allow for a thorough analysis that will help readers understand the extent to which WSS has a multifactorial relationship with the variables targeted in this study. Conclusions The present study expands upon many of the previous WSS studies by exploring novel combinations of variables across one of the largest samples of WSS events. We anticipate that stakeholders will leverage the findings to identify WSS-related factors to target and inform interventions to enhance patient safety. Plain Language Summary Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” This avoidable medical error continues to be significant problem in hospitals and ambulatory surgical facilities (ASFs). Expanding on previous WSS research, the authors of this study took a novel approach: They reviewed and analyzed 644 WSS events reported in Pennsylvania from 2015 to 2024 and identified combinations of clinically related variables, such as type of facility, hospital procedure location, error type, clinician specialty, region of the body, and specific procedure. Among their findings: Most of these WSS events occurred in hospitals rather than ASFs, distributed across operating rooms, interventional radiology, and other procedural locations. The most frequently involved specialties were interventional radiology, pain management, and orthopedics. This study represents one of the largest samples of WSS events examined in a single study. The authors have visualized their deep-dive analysis in 16 figures, tables, and supplemental appendices to help stakeholders comprehend the many combinations of variables contributing to WSS, identify these factors in their own facility, and design interventions to improve patient safety.
Taylor et al. (Fri,) studied this question.