Incidence, patterns, and prevention of wrong-site surgery

Arch Surg. 2006 Apr;141(4):353-7; discussion 357-8. doi: 10.1001/archsurg.141.4.353.


Hypothesis: We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols.

Design: Case series and survey of site-verification protocols.

Setting: Hospitals and a malpractice liability insurer.

Patients and other participants: All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004.

Main outcome measures: Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols.

Results: Among 2,826,367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112,994 operations (95% confidence interval, 1 in 76,336 to 1 in 174,825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases.

Conclusions: Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Humans
  • Incidence
  • Malpractice
  • Medical Errors / prevention & control*
  • Medical Errors / statistics & numerical data*
  • Professional Practice / standards*
  • Safety Management
  • Surgical Procedures, Operative / standards*