In 1998, the Joint Commission on Accreditation of Healthcare Organizations identified important contributors to surgical site misidentification in the operating room (OR), including communication breakdown between surgical team members and the patient, availability of pertinent information, failure of OR policies and procedures, incomplete patient assessment, and distraction. Prior to this, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the likelihood of misidentification in surgical procedures. We hypothesized these guidelines were inconsistently implemented because of the failure to account for the dynamic complex OR environment. Over 40 h of direct observation of the entire care process (from initial consultation through postoperative care) were conducted at two hospitals. Our analysis identified critical process elements that impact the outpatient surgical process of identification. Time pressure, crosschecking, uncooperative communication culture, complexity in the work process, attention/distraction, and documentation concerns make guidelines that rely on verification of the site complicated and vulnerable to error. Suggestions for improvements in processes are made.