Applying fault tree analysis to the prevention of wrong-site surgery

Zachary A. Abecassis*, Lisa M. McElroy, Ronak M. Patel, Rebeca Khorzad, Charles Carroll, Sanjay Mehrotra

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying highpriority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

Original languageEnglish (US)
Pages (from-to)88-94
Number of pages7
JournalJournal of Surgical Research
Issue number1
StatePublished - 2015


  • Fault tree analysis
  • Medical errors
  • Preoperative process
  • Probabilistic risk assessment
  • Scheduling
  • Wrong-site surgery

ASJC Scopus subject areas

  • Surgery

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