Available data have not yet demonstrated a reduction in the incidence of wrong-patient, wrongsite procedures. In an effort to reduce these occurrences, a panel of experts was convened to update New York State’s 2001 Pre-Operative Protocol. The panel analyzed 254 root cause analyses submitted to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) and reviewed the Joint Commission’s Universal Protocol and the current literature. Emerging themes related to wrong procedure events included communications, team dynamics, patient identification, orientation/training, use of available information, site marking, “time out,” and time pressures. The scope and specificity of the New York State Surgical and Invasive Procedure Protocol (NYSSIPP) are expected to reduce the incidence of procedural maloccurrences. NYPORTS provides useful information about systems errors and effectiveness of prevention strategies. This paper provides a model for other agencies interested in establishing protocols to reduce these preventable events
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