Wrong site surgery-where are we and what is the next step?

BACKGROUND: Wrong site surgery is estimated to occur 40 times per week in hospitals and clinics in USA. The universal protocol was implemented by the joint commission board of commissioners to address wrong site, wrong procedure, and wrong person surgery. DISCUSSION: The universal protocol has three principal components: preoperative verification, marking of the operative site, and a time-out. Despite this organized approach to this problem, current data do not demonstrate any progress. In fact some data suggest that the problem may be getting worse. It is apparent that a process relying on surgeon and surgical team memory is doomed to ultimate failure. Recommendations are made for a more in depth checklist process based on the recommendations of the World Health Organization, reports in the literature of known areas of weakness in the current process, and personal experience in hopes of establishing a more bullet proof system to avoid wrong site procedure.