Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

Background: In 2005, guidance on how to prevent wrong site surgery in the form of a national safety alert was issued to all NHS hospital trusts in England and Wales by the National Patient Safety Agency. Objective: To investigate the response to the alert among clinicians in England and Wales 12-15 months after it had been issued. Methods: A before-after study, using telephone/face-to-face interviews with consultant surgeons and senior nurses in ophthalmology, orthopaedics and urology in 11 NHS hospitals in England & Wales in the year prior to the alert and 12-15 months after. The interviews were coded and analysed thematically. Results: The study revealed marked heterogeneity in organisational processes in response to a national alert. There was a significant change in surgeons' self-reported practice, with only 48% of surgeons routinely marking patients prior to the alert and 85% after (p