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Safeguarding Patients: Strategies to Prevent Wrong Site Surgery

Jun 25, 2023 | 0 comments

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Jun 25, 2023 | Essays | 0 comments


Wrong site surgery is a problem that has existed for as long as surgery has been used to treat various conditions. When surgeons perform surgery on the wrong part of the body, it is deemed as wrong site surgery. Wrong site surgery covers the following categories:

  • Surgery carried out of paired organs such as kidneys, eyes and even limbs. Here, the surgeon operates on the wrong organ. For example, instead of operating on the right eye, the surgery is completed on the left eye.
  • The second category is where the right organ is operated upon but the surgery is done in the wrong location. This occurs where the anatomies of the particular body part are quite similar. For example in the same eye surgery, surgery is done on the correct eye but he wrong eye muscle.
  • Finally surgery could be done on the correct part f the body, the correct anatomy but the wrong procedure. This is especially where the surgeries may sound and/or look the same. For example resecting a muscle rather than recession of the same.

In recent times, researchers have added two new categories which include the wrong patient surgery where the individual operates upon happens to be the wrong individual. It also includes the wrong procedures a condition and situation that is becoming more common than all the other categories.  For a long time wrong site surgery was considered a problem of orthopedics where surgeons were most likely to operate on the wrong limb. However, recent reviews have shown wrong site surgery is more of a system problem. Hospitals and health care professionals are becoming more concerned with prevalence of wrong site surgery.


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Background of the Problem

Although the problem has existed for many decades, it is not until the beginning of the millennium there was no singular way of tracking the deaths and injuries resulting from the same. Clinicians and health care specialists rarely if ever heard of the wrong site surgery. However, a report published in 1999 “to err is human” highlighted a problem that has previously been considered a form of weakness. The report allowed hospitals to establish a way of recognizing and reporting wrong site surgery cases. Special concern and attention is being directed to invasive surgery that could easily be detrimental to a patient’s health. The main focus for researchers and professionals is not just directed at reducing the cases of wrong site surgery but also at ensuring immediate recognition and therefore developing more effective measures of correcting the same.

In history the first sighting of wrong site surgery was often considered when doctors and surgeons cut off the wrong limbs during amputation. Before the 19th century, several cases existed where patients had not only lost one limb but in many cases both, and sometimes endured more than one surgery. Many more died or were severely incapacitated by the experience.

Review Of Literature

Technology has allowed cases of wrong site surgery to become more exposed. Such cases have garnered more than enough national attention.  The review of literature shows that cases of wrong site surgery are hard to track. Surgeons in themselves are often less than honest when it comes to reporting cases and patients are more concerned with seeking liability. Both these factors make the availability of the literature minimal. Majority of the literature available often blames WSS on the system. Hospitals and surgery bookings are often done through the system. In majority of the cases, the surgeon has not interacted with the patients. If such a system breaks down, the chances of wrong site surgery become higher. The Joint Commission allows surgeons to record and report voluntarily cases of wrong site surgery. However, the numbers recorded have been dwindling in the past year.

The most common source of data for the wrong site surgery is the legal claims. This number is not accurate enough because majority of the cases are not reported. (O’Neill and Klein 2014) indicated that wrong site surgery is not as a result of bad people doing bad surgery, but rather very good and skilled doctors working with poor systems. In 84% of the reported cases, doctors and other healthcare professionals cited errors in the system or some sort of disruption that in turn led to patients being given the wrong surgery

The universal goal of all wrong site surgery is improvement of safety in hospitals. Injuries and even deaths resulting from wrong site surgery has been on the increase. Canale (2005) shows that As procedures become more and more delicate, a simple error could be detrimental to the patient. The effects of wrong site surgery are not only felt by the patient, they also affect the surgeon. The theatre is a precise arena, and the surgeon in most cases is already dealing with an environment that demands preciseness an error such as this one could be quite defeating to his own skills.

What can be done to prevent WSS

One of the most effective ways of preventing WSS, is through the surgeon. Technology and the involvement of many healthcare professionals means that the surgeon rarely meets the patient. Interaction between the patient and the surgeon is vital. Before the surgery, the doctor should mark the path he intends to take with a permanent marker. This reduces the chances that during surgery he will take the wrong path. Further, it is important for nurses to confirm the markings of the surgery path with the doctors so that everyone is aware, (Fraser and Adams, 2006). Commonly when the patient has been moved to the theatre both the doctors and nurses are more concerned with completing the surgery.  Many hospitals have introduced a simple briefing involving the team for the surgery. During the briefing, team members are able to confirm the procedure an even the area of surgery.

Kwaan et al (2006) have agreed that majority of the WSS issues arise not from surgeon’s era but system failure; there is need to put measure to counter the challenges and weakness of each system. This means mastering the system to understand where the loopholes.

Effect on nursing

One of the main effects of WSS is that nurses are now more commonly faced with the dilemma of reporting cases. On the one hand they have an obligation to the patient should an error occur while on the other hand, they have relationships with the surgeons. Nurses often find themselves torn between supporting patients and on the other hand reporting wrong surgery.

Secondly, nurses are now obligated not just to master the aftercare treatment of patients but also the specific surgery that the patients have been booked for.  In the past, nurses were only obligated to follow the instructions of the doctor. However, Rothman (2006) states that today there is need for them to learn the various procedures, communicate and support the surgeon before and after the surgery bearing the right information.  During the briefing, they are required to produce the right information and support the team in understanding and ensuring WSS is prevented.

Muth and Bellinir (2002) indicate that A big impact on nursing has been the importance of understanding the hospital systems. Nurses are often in charge of keeping and maintain the patient records. By taking detailed records, they can prevent the few chances of WSS occurring. Further, should something go wrong with the system surgeons are often forced to double check and confirm the information they have with the nurse’s records.

Nurses are often in charge of ensuring that all protocols are followed before and after the surgery. While the surgeon maybe exhausted from carrying out the surgery, the team looks up to the nurse to ensure protocols put in place to prevent WSS are followed clearly. The nurse brings the team together ensuring that each team member is aware of what is to be done, how it is to be done and the role to be played by each one of  the team members.


It is important to note that WSS is a condition and situation that is garnering even more attention. With the health of an individual on the line, surgeons are often called upon to be strict in their theater regime ensuing all protocols are adhered to.  WSS has been cited in the payable malpractice injury claims. WSs does not only cause physical injury but also psychological and emotional injury to the patients as well as the surgeons.

Nurses are called upon to follow the universal protocol and speak up when the safety of their patients is in question. The first obligation is to the care of their patients and should something jeopardize the same they are expected to take action. Cases reported are dealt with immediately, in many cases if the problem is established during surgery it can be corrected immediately. However, further treatment and disclosure maybe required when the error is discovered after the surgery. All in all WSS can be easily prevented with a few simple steps.


Canale, S. T. (2005). Wrong-site surgery: a preventable complicationClinical orthopedics and related research433, 26-29.

Fraser, S. G., & Adams, W. (2006). Wrong site surgery. British journal of ophthalmology90(7), 814-816.

Fraser, S. G., & Adams, W. (2006). Wrong site surgery. British journal of ophthalmology90(7), 814-816.

Muth, A., & Bellenir, K. (2002). Surgery sourcebook: Basic consumer health information about inpatient and outpatient

surgeries. Detroit, Mich: Omnigraphics.

O’Neill, P. A., & Klein, E. N. (2014). Wrong-Site Surgery. In Patient Safety (pp. 145-159). Springer New York.

Rothman, G. (2006). Wrong-site surgery. Archives of Surgery141(10), 1049-1050.


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