Anyone faced with a wrong-site surgery near miss or occurrence in his or her facility is encouraged to use this form to aid in the analysis.

Specific instructions for use are included in the form, which may be downloaded for electronic entry or printed for handwritten entry. The form is a PDF and requires Adobe Reader to view and/or use the electronic entry feature.

A "Wrong Spinal Level Analysis Form" and "Wrong Ureter Analysis Form" were released as addendums to this main form and should complement it, as applicable.