What is Wrong-Site Surgery and How Does it Happen?

doctors performing surgery

In the realm of healthcare, few things are as alarming and potentially catastrophic as wrong-site surgery. This term may sound straightforward, but the implications of such errors are grave.

Understanding Wrong-Site Surgery

Wrong-site surgery refers to a surgical procedure performed on the incorrect part of the patient's body. It's a seemingly unbelievable scenario that can have life-altering consequences for the patient. Wrong-site surgery encompasses a range of errors, including operating on the wrong side or part of the body, performing the wrong procedure, or even surgery on the wrong patient.

The Implications of Wrong-Site Surgery

The implications of wrong-site surgery are far-reaching. Not only can it lead to physical harm, prolonged suffering, and additional surgeries, but it also results in emotional trauma for patients and their families. Moreover, it impacts healthcare providers and institutions by causing irreparable damage to their reputation and trustworthiness.

Factors Contributing to Wrong-Site Surgery

Wrong-site surgery is not a result of a single mistake but a chain of errors and lapses in the healthcare system. Here are some of the key factors contributing to wrong-site surgery:


Miscommunication among healthcare teams is a significant factor in wrong-site surgery. This can involve inaccurate documentation, unclear handoffs, or a failure to verify the patient's identity and procedure details.

Inadequate Preoperative Verification

In some cases, the preoperative verification process may fall short. Surgeons and their teams may not thoroughly review the patient's medical records, imaging, and consent forms, leading to a lack of clarity about the correct surgical site or procedure.

Human Factors

Healthcare professionals can make errors due to fatigue, stress, or distractions. These human factors may contribute to lapses in judgment and surgical errors.

Consequences for Patients

The consequences of wrong-site surgery can be devastating for patients. They may experience unnecessary pain, disability, and disfigurement. Some patients require additional surgeries to correct the initial error, increasing the risk of complications and infections. The emotional toll on patients and their families can be immense, leading to long-lasting psychological trauma.

Prevention Strategies

Preventing wrong-site surgery requires a multifaceted approach, involving various healthcare providers. Here are some strategies to mitigate the risk of such errors:

The Universal Protocol

The Universal Protocol, developed by The Joint Commission, is a set of guidelines designed to prevent wrong-site surgery. It includes steps like verifying the patient's identity, confirming the correct surgical site, and conducting a "time-out" before the surgery for the surgical team to review critical information.

Improved Communication

Enhancing communication within healthcare teams is essential. This includes clear and effective handoffs, accurate documentation, and open channels of communication for reporting concerns or errors.

Education and Training

Continual education and training for healthcare professionals can improve awareness of wrong-site surgery and best practices for prevention.

Engaging Patients

Empowering patients to actively participate in their care can also reduce the risk of wrong-site surgery. Patients should be encouraged to ask questions, verify their information, and discuss any concerns with their healthcare providers.

Wrong-site surgery is a distressing and entirely preventable medical error that continues to occur within the healthcare system. It is a stark reminder of the importance of patient safety and the need for continuous improvement in communication, verification processes, and healthcare provider training. By understanding the factors contributing to wrong-site surgery and implementing prevention strategies, we can work towards a healthcare system where such devastating errors are exceedingly rare, ensuring that patients receive the safe and effective care they deserve.

If you’ve suffered serious injuries due to the negligence of a medical professional, reach out to Cunningham Bounds today at (844) 417-0930 to start your journey to recovery and justice.