Adverse Health Events Facts: Wrong-Site Surgery

Updated: January 2008

Background

The Minnesota Department of Health collects information about 27 different kinds of adverse health events, including surgery on the wrong person or body part, falls linked with a death, and serious bed sores. Since 2003, 179 wrong-site surgeries have been reported.

What is wrong-site surgery?

Wrong-site surgery is when a surgeon or other caregiver goes into the wrong part of the body during surgery or an invasive procedure. In some cases, this means that the wrong knee, level of the spine, or eye was operated on. In other cases, a shot or anesthetic injection goes into the wrong place. Sometimes, the mistake is inside the body, when a surgeon operates on the wrong kidney, ovary, or other internal organ that appears on both sides of the body.

Is wrong-site surgery serious?

Wrong site surgery should never happen. It is always a serious event. Sometimes wrong-site surgery is very harmful to patients. In many cases, the patient has to have surgery again in the right place, and that might mean staying in the hospital longer.

Sometimes, though, the mistake is caught at the very beginning of surgery, and it can be fixed right away. If there was an injection on the wrong part of the body, a second injection is usually needed but there is no lasting harm.

Why do these events happen?

Adverse events usually happen because of a problem with a process or a policy, not because of just one nurse or one doctor. Health care is provided by a team of caregivers. The team has to work together to make sure patients get the safest care.

When wrong-site surgery happens, it's usually because there was a problem before the surgery started; maybe a surgical form listed the wrong side, or an x-ray was turned around, or the team didn’t do a final check of the site. Sometimes, a person might notice a problem, but they aren’t comfortable speaking up.

What should hospitals and surgical centers do to prevent wrong-site surgery?

There are steps that every surgeon and surgical team should take before every surgery or invasive procedure:

• Mark the correct surgical site with the surgeon’s initials, and make sure the mark is visible.
• Stop to confirm the location, the procedure, and the patient’s name before beginning the procedure. The whole surgical team should participate in this “time-out.”
• Make sure that everyone knows where on the body the surgery should be, and that they speak up if something looks wrong.

Where can I learn more?

To learn more about what specific hospitals and surgical centers are doing to prevent retained objects, visit the other pages on this site.

Or, contact:

Rachel Jokela
Minnesota Department of Health
651-201-5807
rachel.jokela@state.mn.us