Best Practices for Preventing Wrong Surgery Sentinel Events

Published: 10/14/2025

Sources:
  • Joint Commission
Relevant To:
  • Ambulatory Surgical Centers,
  • Critical Access Hospitals,
  • Hospitals

The Joint Commission (TJC) recently released its annual report of the top most reported sentinel events in 2024. Wrong-site, wrong-procedure, wrong-patient surgery were the second most reported events accounting for 8% of total events reported. In 2024 there were 127 sentinel events classified as wrong site surgery, a 13% increase from 2023.

According to TJC, wrong surgery includes “surgeries or invasive procedures that are performed at the wrong site or on the wrong patient, or that are the …

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