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The Best Ideas to Prevent Wrong Side Surgical Errors

September 10, 2019

The bad news is that surgery done on the wrong side of a body probably is more common than you might think.

The good news is that clear and specific steps exist to avoid this type of medical malpractice. With training and an emphasis on following pre-surgery protocols and communication, wrong side surgical errors are preventable.

How prevalent are wrong side surgical errors?

A study in Spain found that 81 wrong side error incidents were reported in 100 hospitals between 2007-2018, according to a post on MediBulletin, a medical website based in New Delhi, India.

The 81 wrong side surgical errors is probably an under-reporting of the actual number due to the lack of recording of data, said Dr. Daniel Arnal of the Hospital Universitario Fundación Alcorcón, Madrid, Spain, who led the research.

The research was presented at the Euroanaesthesia Congress, which is the annual meeting of the European Society of Anaesthesiology, in Vienna, Austria.

Mayo Clinic Research

Researchers from the Mayo Clinic published a study in 2015, which called these types of surgical errors “never events”, “because they shouldn’t happen — but do.”

The Mayo Clinic study identified 69 “never events” among 1.5 million invasive procedures performed over five years and detailed why each occurred. They used a coding system for human behaviors that was established for investigating military plane crashes.

They found that 628 human factors contributed to the errors overall, roughly 4-9 per event. The “never events” included performing the wrong procedure (24), performing surgery on the wrong site or wrong side of the body (22), putting in the wrong implant (5) or leaving an object in the patient (18).

All of the errors analyzed occurred at Mayo, but none were fatal.

In the Spanish study, 36, or 44 percent, of the total of 81 of the wrong side surgical errors were related to the surgical procedure — and the surgery was actually performed in half of those cases.

The remaining 45, or 56 percent, of the wrong side surgical errors involved anesthesia being administered to the wrong side of the body with an incorrect nerve block performed in 91 percent of cases. Severe harm was caused on three occasions.

The study found about 39, or 48 percent, involved orthopedic surgery (correction of deformities of bones or muscles) and about 23, or 28 percent, involved ophthalmology surgery (treatment of disorders and diseases of the eye).


Wrong side surgical errors are preventable by:

  • Ensuring that every member of a team participating in a procedure follows the surgical safety checklist. This can involve recording information, such as the patient confirming his or her identity and their consent to the surgical procedure; ensuring all medical equipment works properly, and determining if the patient has allergies.
  • Supporting the establishment of a standardized surgical site marking protocol. This involves placing markings, such as adhesive strips, on the part of a patient’s skin where the procedure is to be performed.
  • Working to increase the reporting of wrong side surgical errors and reducing the shame felt by medical teams who make these mistakes.

Wrong side surgical errors are preventable, but what causes them?

Causes can include the absence of or incorrect use of the surgical checklist; rushing and poor communication by surgical team members; lack of continual training; the need for more revision of clinical history and imaging tests; and the need for more communication with the patient about the surgical procedure.

Contact Coplan + Crane Oak Park’s Personal Injury Lawyers today for help with cases of wrong side surgical errors and for help with other cases of medical malpractice, car and truck wrecks and wrongful deaths.