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Wrong-Site Surgery: What You Need to Know

Written by Berkowitz

surgeons in surgery

What is wrong-site surgery? Wrong-site surgery occurs when the surgeon operates on the wrong side of the patient’s body or on the wrong body part, performs the wrong operation, or operates on the wrong patient. Imagine, for example, a surgeon operating on your healthy right kidney instead of your diseased left kidney. Wrong-site surgery is a designated “never” event—a shocking example of medical malpractice that should never happen at all.

Wrong-site surgery is uncommon, but it is not surpassingly rare. According to Becker’s ASC Review, defendants settled 9,744 malpractice claims related to wrong-site surgery from 1990 to 2010. Among these cases, 6% of patients died while about a third suffered permanent injury. If you become one of these unlucky few, you should seek a full financial recovery under Connecticut medical malpractice law.

Types of Wrong-Site Surgery

Surgeons in a surgery site.Wrong-site surgery is generally divided into the following four classifications:

  • Wrong-side surgery. A common example of this is operating on the right eye instead of the left eye. This happens only with paired organs such as eyes, kidneys or ovaries.
  • Surgery on the wrong body part. A surgeon may, for example, operate on the wrong finger, or on the wrong part of the brain.
  • Performing the wrong operation altogether. A surgeon might, for example, completely remove an organ instead of removing a diseased portion of it.
  • Operating on the wrong patient. A surgeon, scheduled to perform a vasectomy on John Doe, operates on Michael Roe instead, due to a case of mistaken identity.

Among these four types of wrong-site surgery, wrong-side surgery is probably the most common, while wrong-patient surgery is the rarest.

Causes and Prevention

In general, it is fair to say that many of the primary causes of wrong-site surgery are rooted in human nature. They may include the following.


Ironically, it is surgical teams with the most experience that are most vulnerable to this risk factor for wrong-site surgery. Surgical teams who have performed a routine operation many times before are most likely to skip monotonous safety protocols.

Large Volume

Conducting a large volume of procedures or emergency surgeries can result in unusual time pressures. Surgical teams who are rushed by heavy workloads are likely to elect to save time by skipping safety protocols.

Understaffing and Turnover

In many cases, understaffing is simply the flip side of time pressure. A high volume of surgeries results in both time pressure and understaffing problems.

A high turnover rate can also lead to errors resulting from the continuum of care issues.


Long hours take their toll on even the most competent of surgical teams. Fatigue leads to “careless” mistakes that would not have occurred if the surgical team had been more alert.

Careless Management

Lack of engagement in safety protocols by senior leadership can increase the likelihood of mistakes. When safety protocols are not a high priority for the leadership of a health care provider, medical mishaps are the inevitable result.

One important safety protocol that may be neglected is redundancy. Relying on only one surgeon to determine critical information, such as the correct incision, can lead to mistakes.

Inadequate training can also result from poor management. This may be due to lack of standardized training procedures.

Most cases of wrong-site surgery can be traced to the failure to follow the standards of the Universal Protocol for Preventing Wrong Side, Wrong Procedure and Wrong Person Surgery, issued by the Joint Commission Board of Commissioners. This protocol has been mandatory in Connecticut since 2004. It established specific safeguards that surgical teams must follow to prevent wrong-site surgery.

Verification Procedures

Tragically, most wrong-site surgery results from errors that are easily preventable and should never have happened in the first place. Wrong-site surgery is most likely to occur when the surgical team fails to perform the following basic verification procedures:

  • Verify the patient’s identity immediately prior to surgery;
  • Double-check the exact procedure to be performed; and
  • Confirm the exact location on the patient’s body where the surgery is to occur, and mark it.

The surgical team should call a “time out” immediately prior to any invasive procedure and before any incision is made to re-verify all of the details of the surgery and the patient. Surgical teams commonly skip this step, an omission that causes a great deal of wrong-site surgery.

Going a Step Further: Other Ways to Prevent Wrong-Site Surgery

A victim of wrong site surgery.The standard protocols listed above occur in the operating room immediately prior to surgery. They should be considered the minimum, not the maximum level of safety precautions. Ideally, the prevention of wrong-site surgery should start long before the operation with system-wide protocols such as the ones that are described below.

The Surgical Safety Checklist

The health care provider should issue a standard checklist, applicable to almost all operations. This checklist should be further supplemented as necessary according to the demands of a particular operation. The World Health Organization (WHO) has prepared a standardized checklist that could be used as a starting point for this endeavor.

Typically, the OR circulating nurse takes responsibility for the checklist. The standardized checklist can be expanded to poster size and placed on the wall of the operating room, so it will not be ignored in the heat of the moment. The circulating nurse should check off every step as it is performed.

Team Communication

Miscommunication among members of the surgical team is perhaps the most preventable cause of wrong-site surgery, and it can occur even if team members otherwise strictly observe routine safety protocols. Team members should verify all critical information during the “time out” period before proceeding with the initial incision. If necessary, every team member should repeat the information individually.

At least one member of the team must be responsible for verifying and marking the site of the surgery on the patient’s body. The same team member should be required to be present in the operating room during surgery to re-verify that the team is operating on the right part of the patient’s body.

Hide the Knives

Keep all surgical instruments out of sight until after the time out has been completed. If instruments are visible, surgeons may become preoccupied with setting up the operation instead of paying attention to safety protocols. The best way to keep the surgical team’s attention is to remove all distractions.

Expand Wrong-Site Surgery Safety Protocols Beyond the Operating Room

In a hospital environment, invasive procedures occur far beyond the boundaries of the operating room. A doctor or other medical staff might insert a catheter or a chest tube in the intensive care unit or the emergency room, for example. Accordingly, wrong-site surgery protocols should apply to every area of the hospital where an invasive procedure occurs, and hospital leadership should emphasize their importance.

Ask the Patient

The surgical team should involve the patient in the verification process to the extent that it is possible to do so. A surgeon might verify the patient’s name, for example, along with the exact medical procedure that the surgeon will perform – removing stones from the left kidney, for example. Of course, this will not apply if the patient is a small child, unconscious, suffering from dementia, etc.

Wrong-Site Surgery Lawsuits: Medical Malpractice Claims

The term “medical malpractice” typically refers to some form of medical negligence. Medical malpractice claims come in two varieties—personal injury claims (for injury) and wrongful death claims (for death). If you win a wrong-site surgery lawsuit or settlement, you will be entitled to monetary damages, which in some cases can be quite substantial.

Winning a medical malpractice claim, however, can be tricky business. To win, you will need to prove that the defendant failed to meet a certain minimum standard of patient care and that this failure caused an injury (or death) that you can quantify in terms of dollars and cents. You will need to prove every claim you make.

One way of meeting your burden of proof is to identify a specific written policy that your health care provider failed to observe that led to wrong-site surgery. The Universal Protocol is suited to this purpose, since its standards are binding on every hospital in Connecticut. A written checklist is ideal evidence for a wrong-site surgery lawsuit. Finally, you might also refer to a book entitled Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Res Ipsa Loquitur

Res ipsa loquitur is an obscure Latin legal term meaning roughly “The thing speaks for itself.” In modern English, we would probably say something like’ “It’s glaringly obvious.” It is related to wrong-site surgery because when someone operates on the wrong site, negligence is obvious. The main problem is often determining the identity of the negligent party, not proving the existence of negligence.

Who Should You File Your Claim Against? The Question of Liability

Who should you file your wrong-site surgery lawsuit against? The most obvious choice is the surgeon. The surgeon, however, is not always the negligent party. In other cases, a third-party defendant shares liability with the surgeon. You might also sue the anesthesiologist, one of the nurses, the surgical prep team, or the hospital itself. If the surgeon is not an employee of the hospital (and many aren’t), the hospital cannot be held liable for the surgeon’s negligence.


Damages for wrong-site surgery are similar to damages for other forms of medical malpractice. If you are the patient, you might receive damages for:

  • Additional medical bills (beyond the bills you would have paid anyway, even without wrong-site surgery);
  • The physical pain and suffering that you endured;
  • Your emotional distress;
  • Lost earnings; and
  • Negative lifestyle changes caused by your injury.

We’re Ready to Help

If you or your loved one has been victimized by wrong-site surgery, don’t just let it pass. Likewise, don’t take a quick settlement offer from the defendant, because it is likely to be inadequate. Act decisively—contact Berkowitz Hanna for a free consultation, so we can evaluate your claim. Call us or contact us online to get the ball rolling today.