What Is Wrong-Site Surgery?

Wrong-site surgery, which is a “never event,” isn’t as uncommon as you may think. This occurs when a surgery is performed on the wrong site or side of a patient’s body, the wrong procedure is performed, or a procedure is performed on the wrong patient. This can happen for various reasons.

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), about 13.4 percent of all cases they reviewed involved wrong-site surgery.

The JCAHO defines wrong-site surgery as “unexpected events in a healthcare setting that cause serious physical or psychological injury, or risk to a patient that is not related to the natural course of the patient’s illness.”

There were 9,744 malpractice settlements for wrong-site surgery claims that were paid from 1990 to 2010, leading to $1.3 billion in settlements. About 6 percent of those patients died, 32.9 percent suffered permanent injury, and 59.2 percent suffered temporary injuries.

The Startling Facts

The JCAHO believes that as many as 50 wrong-site surgeries take place weekly throughout the country. As an effort to combat the number of surgical procedures that occur throughout the U.S. weekly, JCAHO started an initiative called “The Joint Commission Center for Transforming Healthcare Project.”

The project involves eight U.S. ambulatory surgery centers and hospitals measuring their risks of having a wrong-site surgery in their perioperative processes in their facilities. After having found the specific risks, they worked to come up with solutions to solve those issues. By doing this, the number of cases of wrong-site procedures was decreased in the scheduling area, pre-op/holding area, and the operating room.

A study by AHRQ indicated that out of 112,000 surgical procedures evaluated, there was one wrong-site error. That would suggest that a hospital could expect wrong-site surgery once every 5 to 10 years. The authors of the study believe that the JCAHO protocol could have prevented 62 percent of those cases that they reviewed.

The Injuries and Damages

Wrong-site surgery can lead to serious injuries and even result in death. As an example, wrong-site surgery can happen during spinal surgery when a physician operates on the wrong level of the spine. More than 400 surgeons were surveyed by the Agency for Healthcare Research and Quality. They discovered that more than half of the respondents had performed at least one wrong level surgery during their career.

Here are some examples of wrong-site surgeries that occurred within a single year at Rhode Island Hospital:

  • A physician who was in training cut into the wrong side of a patient’s head after a pre-operation checklist was skipped.
  • The correct side of the head wasn’t marked on the consent form. A chief resident started brain surgery in the wrong place, and a nurse witnessed the mistake but didn’t say anything.
  • A neurosurgeon was inserting a drain into a patient’s head and operated on the wrong side of the brain.

Verification errors, distractions, booking errors, inconsistent marking of the site, and similar situations can cause medical malpractice, such as wrong-site surgery. If you, or a loved one, has been the victim of wrong-site surgery, you may be able to pursue a medical malpractice claim. Call Los Angeles medical malpractice attorney Bradley I. Kramer, M.D., Esq., for a free case review.

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