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Wrong-site surgery is still happening: Why?

On Behalf of | Oct 8, 2021 | Medical Malpractice


Surgeons are required to deal with pairs: some patients have two hands or two legs with only one limb requiring treatment; a surgeon must transplant an organ into a second patient, yet the wrong patient gets the transplant. When a surgeon amputates the wrong limb or places a donated organ in the wrong person, these mistakes are called “wrong-site surgeries.” The result of a wrong-site surgery can be catastrophic, but they seem to be a not uncommon occurrence in the nation’s operating rooms.

Several explanations

Doctors who were examined in a recent study offered several explanations for wrong-site surgeries. The most common explanation seems to be physician indifference. As one surgeon put it, most doctors do not believe that they would ever undertake a wrong site surgery and thus, they don’t pay must attention to the location of their operations. Moreover, surgeons rarely take extra precautions to prevent a wrong-site surgery. A study of wrong-site surgeries in Colorado reported that in 2013, 2.7% of patients involved in wrong-site surgeries died, 41% experienced some type of permanent injury, and the mean payment in damages to a wrong-site victim was $127,000.

Experience is not a cure or preventative

Most wrong-site surgeries are performed by physicians with significant experience. A report in the Journal of Neurology reported that 25% of orthopedic surgeons reported performing at least one wrong-site surgery during their careers. A 2007 study found that 25% of surgeons had performed at least one wrong-site surgery during their careers.

Others share the blame

The location of the prescribed surgery can be set for the wrong site by a staff person scheduling the operation. Operating room personnel can be confused if the patient is turned around while being prepped for the surgery. Operative site markings can be rubbed off.

Universal protocol

Most surgeons follow a procedure called the “universal protocol.” Hospitals following the protocol must take three steps to prevent wrong-site surgeries: verify the site before the procedure begins; verify the site using patient care documents; and a final time out before beginning the procedure that lets the operative team consider whether a mistake is about to be made. A study made about two years after the universal protocol was promulgated found that wrong-site surgeries had become only one-third less frequent.


Conclusion. A number of concerned physicians are working to develop operative procedures that will eliminate all wrong-site surgeries, but they are a long way from achieving this goal. Anyone who thinks that they may have been the victim of a wrong-site surgery may wish to consult an experienced medical malpractice attorney for an evaluation of the evidence and advice on the likelihood of recovering damages.