Wrong-Site Surgery

Wrong-site surgery is a broad, generic term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it can also describe performing the wrong procedure on, or performing on the wrong part of, a correctly identified anatomic site.

Events resulting from wrong-site surgery can result in devastating consequences for all involved. For example:

The public naturally regards wrong-site surgery as a shocking, egregious, and preventable medical error. Media coverage often follows these events, such as the following:

Wrong-site surgery events are often perceived as rare; however, despite the Joint Commission introducing its Universal Protocol to address the problem in 2004, instances of wrong-site surgery errors still occur. For example, wrong-site surgery was the third most common sentinel event for the years 2016, 2017, and 2018 (Joint Commission "Sentinel"; Joint Commission "Summary"). Wrong-site surgery is also thought to be underreported, and its true incidence is likely to be much higher than official reports indicate. In addition, clinicians may perceive that, because such events are rare, such errors cannot happen to them—a mistaken perception that has been identified as a barrier to eliminating these events (Seiden and Barach).

Although some incidents of wrong-site surgery may be attributed solely to the clinician performing the procedure, the majority of wrong-site events occur because of multiple system or process failures that involve the entire multidisciplinary operating team, as well as organizational processes that set the stage for the occurrence of a catastrophe in the operating room (OR).

Risk managers committed to decreasing risk of wrong-site surgery in their organizations will need...