Avoiding wrong site surgery: a systematic review

Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S28-36. doi: 10.1097/BRS.0b013e3181d833ac.


Study design: Systematic review.

Objective: To report the incidence and causes of wrong site surgery and determine what preoperative measures are effective in preventing wrong site surgery.

Summary of background data: From 1995 to 2005, the Joint Commission (JC) sentinel event statistics database ranked wrong site surgery as the second most frequently reported event with 455 of 3548 sentinel events (12.8%). Although the event seems to be rare, the incidence of these complications has been difficult to measure and quantify. The implications for wrong site surgery go beyond the effects to the patient. Such an event has profound medical, legal, social, and emotional implications.

Methods: A systematic review of the English language literature was undertaken for articles published between 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify the articles defining wrong site surgery and reporting wrong site events. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation criteria and disagreements were resolved by consensus.

Results: The estimated rate of wrong site surgery varies widely ranging from 0.09 to 4.5 per 10,000 surgeries performed. There is no literature to substantiate the effectiveness of the current JC Universal Protocol in decreasing the rate of wrong site, wrong level surgery.

Conclusion: Wrong site surgery may be preventable. We suggest that the North American Spine Society and JC checklists are insufficient on their own to minimize this complication. Therefore, in addition to these protocols, we recommend intraoperative imaging after exposure and marking of a fixed anatomic structure. This imaging should be compared with routine preoperative studies to determine the correct site for spine surgery.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Checklist / standards
  • Humans
  • Iatrogenic Disease / epidemiology*
  • Iatrogenic Disease / prevention & control*
  • Incidence
  • Medical Errors / prevention & control*
  • Neurosurgical Procedures / adverse effects*
  • Patient Identification Systems / standards
  • Postoperative Complications / epidemiology*
  • Postoperative Complications / prevention & control*
  • Preoperative Care / methods
  • Preoperative Care / standards
  • Safety Management / standards
  • Spinal Diseases / surgery*