Surgery requires precision at every stage, from pre-operative planning through the final procedure. When the systems designed to protect patients from preventable harm break down, the consequences can be permanent. Wrong-site surgeries, wrong-patient surgeries, and other serious preventable errors fall into their own category in healthcare quality reporting, classified as “never events” because they should not occur when proper protocols are followed.
At Davis & Davis, John A. Davis, Jr., Esq. and Steven R. Davis, Esq. represent patients in Houston and across South Texas who suffered harm because of a surgical error, including procedures performed on the wrong body part, the wrong patient, or with the wrong implant. If you believe a surgical error caused your injury, our team can evaluate whether the care you received departed from the accepted standard.
What Are “Never Events”?
The term “never event” was introduced to describe serious adverse outcomes in healthcare that are clearly identifiable, largely preventable, and of concern to both patients and providers. According to the Agency for Healthcare Research and Quality, the category includes 29 serious reportable events, among them wrong-site surgery, wrong-patient surgery, wrong-implant surgery, and the unintended retention of a foreign object inside a patient after a procedure is complete.
The classification exists because these errors have a known set of prevention strategies. When the right protocols are in place and followed consistently, these outcomes should not occur. Their persistence in healthcare settings despite the availability of safeguards is what makes them both medically and legally significant.
Types of Wrong-Site Surgical Errors
Wrong-site surgery can take several forms. A surgeon may operate on the wrong side of the body, for example removing or operating on the left structure instead of the right. A procedure may be performed at the wrong spinal level. In some cases, surgery is performed on an entirely different patient. An incorrect implant or prosthetic may be placed. In rare cases, the wrong procedure entirely may be performed on the correct patient.
Each of these errors has the potential to cause harm that extends well beyond the operating room. A patient who undergoes unnecessary surgery faces the combined risks of anesthesia, the operative procedure itself, and the recovery period, none of which they consented to. Meanwhile, the condition that actually required treatment may go unaddressed for additional weeks or months.
How Wrong-Site Surgeries Happen
Research consistently identifies a core set of contributing factors in wrong-site surgery cases. Failure to follow established policies and protocols is the most frequently cited contributing factor. Communication failures within the surgical team, inadequate documentation, errors in patient identification, and failure to conduct a required pre-operative time-out are also common contributors.
The Joint Commission introduced the Universal Protocol for preventing wrong-site, wrong-procedure, and wrong-patient surgery. That protocol requires surgical teams to complete a pre-procedure verification of the patient’s identity and intended site, mark the surgical site before the procedure, and conduct a time-out immediately before the first incision. When teams skip, rush, or incompletely execute these steps, the risk of a preventable error increases substantially.
Patient Protections and Reporting Requirements in Texas
Texas law requires that wrong-site surgeries and similar never events be reported through the state’s adverse event reporting system. Hospitals must investigate these events, identify contributing causes, and implement corrective measures. Patients who suffer harm as a result of a wrong-site surgery have the right to a full explanation of what occurred, including the findings of any institutional review.
Under Texas Civil Practice and Remedies Code Chapter 74, patients injured by surgical negligence may pursue a medical malpractice claim against the operating surgeon, the facility, and any other providers whose conduct contributed to the error. The statute of limitations is generally two years from the date of the incident.
Related Never Events: Retained Foreign Objects
A closely related category of never events involves the unintended retention of surgical instruments, sponges, or other materials inside a patient following a procedure. Like wrong-site surgery, this error is considered preventable through proper counting protocols and the use of tracking technology. Patients who experience unexplained complications after surgery and have not received a satisfactory explanation may benefit from consulting an attorney about whether a retained foreign object contributed to their ongoing symptoms.
Pursuing a Claim After a Surgical Never Event
A never event by its classification signals a departure from what is considered acceptable medical practice. However, proving a malpractice claim still requires demonstrating that the error fell below the standard of care, that the departure caused harm, and that compensable damages resulted. Texas requires a qualifying expert report within 120 days of filing suit, making it important to work with an attorney who can engage the necessary medical professionals and preserve evidence promptly.
John A. Davis, Jr., Esq. and Steven R. Davis, Esq. have the knowledge and resources to evaluate wrong-site surgery and other surgical never event claims. If you or a family member underwent surgery and believe the outcome reflects a preventable error, our attorneys can review your records and advise you on your options. Compensation may be available for additional surgeries, extended recovery, lost wages, and the pain and suffering associated with the error.
Contact Davis & Davis for a free consultation. You can reach us through our online contact form.
Frequently Asked Questions About Wrong-Site Surgery and Never Events
What qualifies as a surgical “never event”?
A surgical never event is a serious, largely preventable adverse outcome that should not occur when proper safety protocols are followed. Examples include operating on the wrong body part, performing a procedure on the wrong patient, implanting the wrong device, and leaving a foreign object inside a patient after surgery. These events are classified separately from other complications because effective prevention strategies exist.
How does a wrong-site surgery happen if hospitals have safety checklists?
Research indicates that the primary contributing factor is failure to follow established protocols, not a lack of protocols. When surgical teams skip or rush through required steps such as the pre-operative time-out or surgical site marking, the risk of a preventable error increases significantly. Fatigue, poor communication between team members, and inadequate staffing can also contribute.
Can I file a malpractice claim after a never event in Texas?
Yes. A surgical never event is generally strong evidence that a departure from the standard of care occurred. However, a malpractice claim still requires demonstrating that the error caused measurable harm. Texas law requires a qualifying expert report within 120 days of filing suit, so consulting an attorney promptly is important to meet that deadline.
Who can be held responsible for a wrong-site surgery?
Responsibility may fall on the operating surgeon, the anesthesiologist, other members of the surgical team, and the hospital or surgical center itself. Texas law allows claims against multiple parties when more than one provider or institution contributed to the error through separate acts of negligence.
What steps can I take to reduce the risk of a wrong-site surgery?
Patients can reduce risk by confirming the intended surgical site directly with the surgeon on the day of the procedure, asking about the facility’s time-out protocol, and actively participating in the pre-operative verification process. You have the right to ask questions and verify that the team is prepared to operate on the correct site before anesthesia is administered.
