Wrong Site Surgery: The Scary Truth

You may think going in for a surgical procedure is routine, they do it every day, and it’s their norm – but is it?  The scary truth is that more surgeries than you think do not go as planned and all we can do is hope that we don’t end up as a statistic when it’s over.  Wrong site surgery means anything from surgery on the wrong site, wrong side of the body, the wrong procedure, the wrong implant, or the wrong patient (Hempel et al., 2015).  With the advancements of medicine, greater levels of education, and innovative technology the ultimate goal is to do everything possible in order to prevent such sentinel events, or events that should never occur under any circumstance, such as wrong site surgery.

Extensive preparation is involved in order for a surgical event to even be performed, including preparing the patient days, or even weeks in advance.  Also, right before surgical procedures begin there is typically what is referred to as a “time-out” period.  During this period, the team of medical professionals involved in the procedure will all agree on all the details of the procedure that is to be performed – such as the demographics of the patient, the site of the procedure that should have been previously marked, the correct side of the body, and what procedure is supposed to occur for that particular patient.  The “time-out” period occurs in order to prevent such surgical errors – however sometimes they occur regardless of how prepared the staff may be.

It has been found that wrong site surgery errors constituted 12.7% of all unanticipated events in the health care setting that caused death or severe psychological or physiological injury to a patient between the years of 2004 and 2015 (Moshtaghi, 2017).  This means that 1 of every 112,000 surgical procedures in the operating room go wrong, it does not seem like much and it seems infrequent enough for us not to worry too much about the next time we have to have a procedure done (Agency for Healthcare Quality and Resarch, n.d.).  In other words, it means that errors such as wrong site surgery likely occur in any individual hospital at a rate of one error every 5 – 10 years (Agency for Healthcare Quality and Research, n.d.).  However, these errors typically result in extremely negative consequences, and possibly death for the individual involved.  Could you imagine waking up from surgery to your left lower leg having been amputated when you were supposed to just have your left foot amputated?  The psychological issues that follow can be very hard on both the individual involved and their family, and could result in more health issues for them down the road.

Ultimately, facilities work very hard to follow the strict rules and regulations that have been set forth by their governing agencies to prevent such horrible errors from occurring. However, it is a good idea for the public to be informed that such events do actually occur despite how normal they may think the surgical routine may be.  One can never be too educated about their health, because the more educated and informed you are the better chances you have at a life more free of health issues and stressors.


Agency for Healthcare Research and Quality. “Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery.” (n.d). PSNet, psnet.ahrq.gov/primers/primer/18/wrong-site-wrong-procedure-and-wrong-patient-surgery.

Hempel, S., Maggard-Gibbons, M., Nguyen, D. K., Dawes, A. J., Miake-Lye, I., Beroes, J. M., Booth, M. J., Miles, J. N. V., Shanman, R., & Shekelle, P. G. (2015). Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA surgery150(8), 796-805.

Moshtaghi, O., Haidar, Y. M., Sahyouni, R., Moshtaghi, A., Ghavami, Y., Lin, H. W., & Djalilian, H. R. (2017). Wrong-site surgery in California, 2007-2014. Otolaryngology–Head and Neck Surgery157(1), 48-52.