Wrong Site Surgery

How You Can Prevent Wrong Site Surgery

anesthesia, receiving anesthesia, surgery anesthesia
Speak Up Before You Receive Anesthesia.

What is Wrong Site Surgery?

Wrong site surgery is an extremely serious but preventable surgical complication where a) the right surgery is performed on the wrong person or b) on the wrong body part OR c) the wrong procedure is performed.  

Here are some examples of wrong site surgery:

a) Mary goes to the hospital for a left knee replacement.  Instead she receives a coronary artery bypass graft.

b) Bob goes to the hospital for a left knee replacement.

  Instead he receives a right knee replacement.

c) June goes to the hospital for an appendectomy, she instead receives a hysterectomy, then has to return to surgery for the correct procedure.

These examples are very serious, but can be corrected with an additional surgery.  Some wrong site surgery results in devastating outcomes that cannot ever be fixed. Examples of wrong site surgery performed include:  operating on the wrong side of the brain of a 15 year old boy, leaving him severely brain damaged, in another case the wrong eye of a patient who had a healthy eye and a cancerous eye was removed, resulting in total blindness.

How Common Is Wrong Site Surgery?

Wrong site surgery is underreported, meaning that the statistics are inaccurate because less than half of all states require these incidents to be reported so the public may never know about them.  Current reports indicate that approximately 1 in 25,000 surgeries is a wrong site procedure, but the real number could be much closer to 1 in 10,000 when unreported errors are estimated.

  According to statistics generated by the National Practitioner Data Bank, 80 never events (wrong site or a surgical instrument left in a patient) happen each week.      

One in 10,000 procedures may sound like great odds for a patient, but some major surgery centers, such as large university programs, often perform over 175,000 cases a year.

  If 1 in every 10,000 patients is expected to have a wrong site surgery, that facility could have as many as 17 wrong site errors per year.  Clearly this level of error is not acceptable. 

What Can Be Done to Prevent Wrong Site Surgery?

The Joint Commission, a group that provides accreditation to hospitals in the United States, has determined that wrong site surgery is a “never event” because it should never happen.  Wrong site surgery is entirely preventable, and to do that, protocols have been recommended to prevent wrong site surgery.  

Protocols To Prevent Wrong Site Surgery Include:

Preoperative Verification:  This  means prior to the beginning of surgery, all relevant information pertaining to the case is available.  The staff can access this information, such as the patient’s chart, x-rays and CT scans, and verify the site of the surgery to be performed.  For example: Emily is in the hospital for a left knee replacement.  Looking at her x-rays, the staff can confirm that the left knee does in fact have joint disease and should be replaced, which is confirmed by the physician’s note in the chart.


Marking the Site: Prior to the patient being given sedatives or anesthesia, the surgical site will be marked.  This is typically done by the surgeon or OR staff.  With a marker, the skin at the site of the surgery is written on.  For example: Emily is in the hospital for a left breast lumpectomy.  Her left breast will be written on with a marker indicating the site of the tumor that is to be removed.  

Time Out: Before a procedure can start, and ideally before the patient is given any anesthesia, a time out is performed verifying the name, procedure and site.  For example, the circulating nurse might say, “This is Emily Elizabeth Smith, she is here for a left knee replacement with a titanium knee implant.” 

How You Can Prevent Wrong Site Surgery

This part is actually rather easy.  Pay attention to what the doctors and nurses are saying prior to surgery.  When they are marking the site, pay attention! Are they marking the knee that hurts or the good one? During time out, they will say the patient’s name, which should be your name, if it isn’t, speak up immediately.  

If you have any concerns, speak up, quickly and clearly, and make your concerns known.  A few moments spent clarifying who you are and why you are having surgery can make a huge difference.


Surgical errors: In ORs, “never events” occur 80 times per week. American Medical News.  Accessed July, 2015. http://www.amednews.com/article/20130121/profession/130129976/2/

Wrong Site Surgery: A Preventable Medical Error.  National Institutes of Health.  Accessed July, 2015.  http://www.ncbi.nlm.nih.gov/books/NBK2678/box/ch36.box1/?report=objectonly

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