• Brian Bjørn, Louise Isager Rabøl, Elisabeth Brøgger Jensen, and Beth Lilja Pedersen.
• H:S Direktionen, H:S Enhed for Patientsikkerhed, H:S Hvidovre Hospital, Afsnit 023, Hvidovre.
• Ugeskr. Laeg. 2006 Nov 27;168(48):4205-9.

IntroductionThis paper illustrates how reporting of adverse events can be used to introduce changes in an organization. Starting from reports of incidents on wrong-site surgery, a method to prevent them and its implementation in the Copenhagen Hospital Corporation (H:S) are described.Materials And MethodsThe H:S adverse event database, the Danish Patient Insurance Association and international sources were searched to estimate the extent of wrong-site surgery. A method to prevent wrong-site surgery developed by the U.S. Department of Veterans Affairs was adapted for Danish conditions. It was introduced as "The Five Steps" in H:S in May 2005, accompanied by an information campaign.ResultsWrong-site surgery incidents are rare: reports in the H:S show an occurrence of 1:32,500 surgical procedures, consistent with international figures. Seven root cause analyses were performed and showed a need for a more structured identification and communication process among the members of the operating team. The Five Steps were designed to prevent such problems. None of the Five Steps is in itself new or revolutionary. The crucial parts are systematization of the identification process and increased communication among the members of the operating team. The procedure is not associated with substantial resource utilization and involves more a change in culture than an investment. The method can be widely implemented in hospitals in Denmark without major changes.ConclusionWrong-site surgery is a rare but serious adverse event. This paper describes the results of root cause analyses after reports of incidents in the H:S. The analyses showed a need for better and more structured communication and identification of patients before surgical intervention.

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