The National Quality Forum includes wrong-site surgery events as Serious Reportable Events and defines surgery as having occurred when skin or mucous membranes and connective tissue are incised or the procedure is performed using an instrument that is introduced through a natural body orifice.To gain further insight into the elusive causes of wrong-site surgery, the Authority began several wrong-site surgery patient safety initiatives: conducted site visits at volunteer facilities, began collecting specific detailed information about wrong-site surgery near misses and events, and set up a Web resource that provides current information for in decreasing risks for wrong-site surgery.