PSA_Logo1_Color - Copy.png

Increase Noted in Reported Wrong-Site Surgery Events From Interventional Radiology

Wrong-site surgery (WSS) is a well-known type of medical error that continues to occur in healthcare facilities. Wrong-site surgery involves all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or wrong site, including wrong level of a correctly identified anatomic site. 

The National Quality Forum (NQF) defines surgery as “an invasive operative procedure in which skin or mucous membranes and connective tissue is incised or an instrument is introduced through a natural body orifice. Surgery begins, regardless of setting, at the point of surgical incision, tissue puncture, or the insertion of an instrument into tissues, cavities, or organs.”


Research published by the Patient Safety Authority (PSA) revealed that on average 1.42 WSS events occur per week in Pennsylvania. While it is true that a majority of WSS events occur in perioperative areas, a steady number of these events arise outside of the operating room (OR) in areas such as interventional radiology (IR).

In our December 2020 study published in Patient Safety, research found that the “frequency of WSS was consistently greater in the hospital OR than IR; nevertheless, IR experienced a range of 6 to 13 WSS events per year, over the five-year period.”

Ongoing research into reported WSS events has revealed an alarming finding. For the period January 1, 2023, through March 31, 2023, there were eight WSS events originating from IR. These reported WSS events (examples below) included wrong-site, wrong-side, and wrong-procedure cases. The number of IR WSS cases in the first quarter of 2023 was the highest quarterly total since 2015. 

“A patient goes to IR for nephrostomy tube placement. Upon return to the inpatient unit, it is realized that the tube was placed on the wrong side. The patient returns for the correct tube placement the following day.”

“… patient with a compression fracture of T-12 vertebra … underwent a kyphoplasty in IR … after reviewing CT results, MD discovered the T-12 fracture remained with kyphoplasty being performed on T-11 …”

In 2008, the Standards of Practice Committee of the Society of Interventional Radiology released the current “Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of The Joint Commission ‘Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery’ to the Practice of Interventional Radiology.” These guidelines supplement The Joint Commission Universal Protocol, and the PSA/Pennsylvania Department of Health Final Recommendations to Ensure Correct Surgical Procedures and Correct Nerve Blocks.


We encourage facilities to review/revise their Universal Protocol policies and procedures and monitor for compliance to decrease the likelihood of a future WSS event both in perioperative areas and interventional medicine departments.

Click here to see how interventional radiology events are reported into the Pennsylvania Patient Safety Reporting System (PA-PSRS) using the reporting decision tree.

Improving MRI Safety

Due to the extreme risks of using high-powered magnets during magnetic resonance imaging (MRI), best practices recommend establishing four safety zones around the MRI scanner, with increasing levels of restriction for personnel and screening for metal objects that could cause harm to patients or staff should they enter a strong magnetic field. Over 18 months at one facility, 37 MRI safety events were reported, 59% of which occurred in Zone IV (the highest level, indicating the room where the magnet is located)—and one of which caused harm to a patient.

In response to this troubling trend, the facility conducted an event review and implemented numerous process changes, including color-coded pocketless scrubs to prevent staff from inadvertently carrying equipment such as phones or scissors into Zone III (the control room) and Zone IV; use of three types of metal detectors; and enhanced multiple screenings and two time-outs with the entire team for metal screenings. Anyone entering Zone III is screened and Zone III undergoes a daily risk evaluation to search for any metal objects. The culture of the MRI department has also shifted to empower staff to manage all aspects of safety in their locations. All these collaborative efforts by Quality and Safety, the MRI Safety committee, MRI staff, and leadership has improved safety for staff, patients, and their families.

Read More Stories That Made a Difference

Assessing Equipment, Supplies, and Devices for

Patient Safety Issues

To care for patients, healthcare staff rely on a host of medical equipment, supplies, and devices (ESD) every day. So when a medical instrument fails or isn’t maintained or used correctly, the health and safety of patients can instead be compromised. A team of researchers reviewed 450 patient safety event reports related to ESD to identify the most common safety concerns and the human factors usability issues contributing to them.

Data showed that the most frequently reported ESD-related safety issues were malfunction, sterilization, usability, and physically missing. Their detailed findings and insights, along with the patient safety procurement assessment tool based on their analysis, may help guide facilities in selecting ESD and making changes in their policies and procedures, and enhance training.

Facebook            Instagram            LinkedIn            Twitter            YouTube

This communication is intended to support reporting facilities and patient safety programs in their work with the Patient Safety Authority. If you feel you have received this email in error, please contact the PSA before clicking "Unsubscribe" below.