Wrong-Site Surgery is still Happening…

Surgeons have learned earlier what it cost to approach the wrong extremity while performing surgery. because we were more often the one found guilty. Anybody has certainly a history to count but some may have taught it happens only to an orthopedist. Let us review the subject and share the devastating experience of any patient who may have been the one in cause. We will try to visualize the negative impact as well as the way such event can impose on the entire surgical team and on the facility where such mistake was produced.

Medical licenses revoked or suspended for the surgeons, the nurses and other penalties that such incident may have generated. Indemnities to pay may have forced many healthcare insurances companies to stop covering the physicians or their team for wrong person surgery or other mistakes committed around the surgical theater. If surgery is performed on the wrong side or on the wrong person or simply if a mistake was committed like leaving a sponge or an instrument in the peritoneal or thoracic cavity. Indeed, the orthopedists are often culprit because it is said that 84% of the wrong side surgical side were during orthopedic procedures and 78 % of wrong site eye surgery resulted in malpractice cases.

It may be difficult to know exactly the number of cases, but they are considered like 10 % of all cases reported with maybe an incidence of 100,000 cases. Hand surgeons or orthopedic surgeons account for the most with around 1 out of four or five among surgeons with more than 25 years of experience. These mistakes remain preventable medical errors that can be avoided especially if standardized procedures are implemented in the peri-operative setting. The incidence in wrong site surgery has increased during the recent years from 15 in 1998 to 592 in 2007. The cases were mainly found among orthopedic or podiatric surgeons’ cases as well as general surgery and urological or neurological cases.

The Joint Commission issued out guidelines to target these preventable errors. A “time-out” was created to check on the identification of the patient using two identifiers and to eliminate the wrong-site/wrong patient using a preoperative verification process to check on the documentation for the surgical procedure. A pen also is used by the surgeon to identify the operative site prior to the sterilization of the extremity. Many like to do a sign or simply sign the site to avoid confusion.

Those become standard procedures imposed by the joint commission on the hospital but they can vary a little when you deal with a surgical center or a physician office. Patients still need to be vigilant when they are undergoing any surgical procedure. Any breakdown in the routine may bring a wrong side surgical incident. Many reasons were discovered why such system may fail and issues like communication failure (70%), non-compliance (60%), lack of leadership (46%). Hospital Operating room have bought their modifications to adopt their routine especially if this is an emergency and multiple procedures are scheduled like in a trauma case etc.

This is the American Academy of Orthopedic Surgeons (AAOS) and the North American Spine Society who started to address the problem years ago, studying the numerous malpractice cases in which orthopedic surgeons were involved. An awareness campaign to encourage the marking of the right surgical site (“Sign your site”), later a “no” was written on the wrong site as well… others have adopted a “X” etc. to confirm the proper side. This is in 2003 that the Joint Commission convene a summit with the AAOS and other leaders in the field to secure a protocol looking at preventing Wrong Site Surgery and Wrong Person Surgery.

If the goal of this experience was to drastically reduce or eliminate such problem in creating a standardized routine during the pre-operative period, verifying the patient and marking the proper site prior to being sedated, it bought excellent results but unfortunately, did not eliminate completely the incidence of such problem. Wrong procedure, wrong site and wrong person surgery can be prevented and those protocols are trying to eliminate this problem once for all. These precautions aimed at avoiding these mistakes by prevention.

There are three key-elements for the system to be functional. First, the pre-operative verification process. Second, the marking of the surgical site. Third the Time-out in the operating room theater prior to initiation of the procedure. It is necessary to use these steps in ambulatory care, hospitals and critical access hospitals and office-base settings.to implement and adhere to such protocol. Recently, such preventions were also introduced by the Joint Commission during their accreditation process for healthcare organizations.

The Association of perioperative Registered Nurses (AORN) has also worked in association with the Joint Commission to develop a “Correct site Surgery Tool Kit” designed to assist healthcare providers in implementing the protocol. The American College of Surgeons, The American Society of Anesthesiologist, the American Hospital Association, the American Association have of Ambulatory Care and the American Society for Healthcare Risk Management have all endorsed the kit. In the kit, there is a CD-ROM for education, a pocket reference card promoting identification, marking and time out, a template to facilitate the development of a policy at a facility, a copy of the universal protocol program, a letter to the nurse, physicians and executive officers and healthcare managers and finally information for the patient.

The Veteran Administration has added a consent form asking for two members of the surgical team to review that patient information and radiological images belonging to the patient prior to the start of the procedure. Other hospitals added an OR briefing tool to initiate a dialogue between the anesthesiologist, the nurses and the surgical team… The British National Patient Safety Agency just introduced a risk management tool enforcing double-checking and identification. Hospitals and surgical centers are constantly improvising their routine to bring an automatism in their checking points, allowing the nurses to evaluate their policies and procedures in avoiding being less dependent on memory.

Once an institution has adopted the universal protocol for WSS, all health professionals need to comply with the protocol. The reported cases will continue to increase as healthcare organizations become more transparent. Recently in July 2021, a university hospital in Cleveland OH reported that one of its surgical team transplanted a kidney into the wrong patient. The incident was still being investigated while two employees were placed on administrative leave. In April 2020, an interventionist radiologist placed a kidney stent into the wrong kidney of an 80-year-old patient under fluoroscopic guidance at a hospital in West Palm Beach Florida. Surgery performed on the wrong patient, the wrong body-part, or the wrong-site of the body may be rare and distressing but it garners more attention when it happens.

Wrong sites surgery happens to surgeons in their 45-50’s and if someone has ever taught that such error was due to the inexperience, it is not the case. Certain specialties have more errors like with the hand specialists. The spine specialists, especially the orthopedists repot having performed at least one-wrong-site surgery during their career.  fusing the wrong segment. The neurosurgeon with a wrong side craniotomy. Wrong side surgery are also done by ophthalmologists, urologists etc. Mistakes are not only done by the physician but the staff scheduling the patient in the operating room. Radiologist, Pathologist can perform mistakes when writing their reports. Many people confuse right and left and studies have shown that at least 14 % of people have difficulties in distinguish right from left. If a patient is in a prone position the right and left leg can become more difficult to discern.

Operative markings on the skin can be rubbed off during the surgical prep and can become difficult for the surgeon who is outside scrubbing especially in spine cases or the markings can be hidden by the surgical draping. This is why the three steps to prevent errors were taken by the joint commission: the pre-operative verification (documents), the marking of the surgical site and the “time-out” in the OR. All activities cease during the time-out. Please use wisely these recommendations while in the operating rooms.

If we have to think that a wrong-site surgical error is a failure of the system, let us work together to eliminate such mistakes in all surgical theaters and arenas where surgical procedures are performed.

Maxime Coles MD, Boca Raton FL



1-    Agency for Healthcare Research and Quality Medical Errors: The scope of the problem. Fact sheet. Publication No AHRQ 00-P037

2-    Joint Commission Special Report: Helpful solutions for meeting the 2006 National Safety goals Joint Commission Perspectives on Patient Safety. 2005 August; 5(8); pp 1-15.

3-    Kwaan MR, Studdert DM, Zimner MJ et al.: Incidence, Patterns and Preventions of wrong-site surgery. Arch Surg 2006:141: pp 353-358. (PubMed).

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6-    American Academy of Orthopedic Surgeons: Report of the task force on wrong-site surgery Available at htpp://www:aanos.org/wordhtml/meded/tasksite.htm

7-    Robeznieks A, getting it right: Florida Board cracking down on wrong-site surgery: Mod Healthc: 2005:35(34) pp 18-20.

8-    Sanfl NM, Universal Protocol for preventing wrong procedure, wrong person surgery. J Perianesth Nurs. 2004:19:348-351(PubMed).

9-    Veterans Health Administration, Department Veterans Affairs. VHA Directive2004-028: ensuring correct surgery and invasive procedures at http://www.va.gov.ncps/Safety/Topics/CorrectSurgDir.DOC (Sept 2006)

10- Perlow DL, Perlow SM. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg, 2003; 85A:1849(PubMed)

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