Wrong-site surgery is an operation performed on the wrong part of the body, on the wrong side, or at the wrong level of the spine. The same category includes performing a different procedure than the one planned and operating on the wrong patient. Patient safety researchers call these errors “never events” because they should not happen when basic verification steps are followed, yet they still occur in hospitals, outpatient surgery centers, and procedure rooms.
This post first ran in February 2015. Here, the Houston medical malpractice attorneys at Davis & Davis explain how often these surgical errors happen, why the safety steps meant to stop them sometimes fail, what the medical records can show afterward, and how Texas law treats a claim for wrong-site surgery.
What Counts as Wrong-Site, Wrong-Procedure, or Wrong-Patient Surgery
Researchers often group these mistakes together because they share the same root problem: the surgical team loses track of who the patient is, what operation was planned, or where it should be done. Common examples include operating on the left knee when the right knee was scheduled, fusing the wrong level of the spine, removing the wrong tooth or the wrong lesion, or performing a procedure that was meant for another patient.
Each of these errors can leave a patient with an operation they never needed and the original problem still untreated, which often means a second surgery, a longer recovery, and new risks. Our article on the trauma of a wrong-site surgery looks more closely at the physical and emotional toll these mistakes can take.
How Often Wrong-Site Surgery Happens
Wrong-site surgery is rare for any single operation, but it is not rare across the health care system. According to the Agency for Healthcare Research and Quality’s patient safety primer on wrong-site, wrong-procedure, and wrong-patient surgery, a frequently cited study estimated that about 1 in 112,000 operating-room procedures involved one of these errors, which works out to roughly one event every five to ten years at an individual hospital.
That estimate covered only operating rooms. The same primer notes that counting other settings, such as ambulatory surgery and interventional radiology, may raise the rate significantly, and that a study of Veterans Affairs data found that half of these errors happened during procedures outside the operating room. Because so many procedures are performed every year, the error can happen to anyone, at any type of facility.
Why Wrong-Site Surgery Still Happens
Root cause analyses of these events consistently point to breakdowns in communication. Many errors begin well before the patient reaches the operating room, for example when a scheduling request, consent form, or imaging study lists the wrong side or the wrong level and no one catches the mismatch. Other contributing factors include not using a checklist, emergency or rushed surgery, inadequate review of the medical record, incomplete patient assessment, and failing to mark the surgical site.
Problems can also occur inside the operating room. Time-outs may be rushed or treated as a formality, production pressure may push a team to start before every question is answered, and site marking practices can be inconsistent. In one analysis cited by AHRQ, staff were sometimes unsure whether a mark meant “operate here” or “avoid this area.”
The Universal Protocol and Its Three Steps
To prevent these errors, accredited hospitals, ambulatory surgery centers, and office-based surgery facilities follow the Joint Commission’s Universal Protocol. It has three parts, and each one is meant to catch a mistake the others might miss:
- Pre-procedure verification: The team confirms the patient’s identity, the planned procedure, and the site against the consent form, medical records, and imaging before surgery.
- Site marking: A member of the surgical team marks the operative site on the patient’s body, ideally with the patient involved, so the location is unambiguous.
- Time-out: Immediately before the procedure starts, the whole team pauses to agree on the patient, the procedure, and the site, and anyone can raise a concern.
AHRQ notes that some wrong-site errors would still occur even with full adherence to the protocol, because a mistake that enters the paperwork early can be carried through every later check. That is why careful verification from scheduling through the time-out matters so much.
What the Medical Records Can Show After a Wrong-Site Error
When a patient learns that the wrong site, procedure, or patient was involved, the records usually tell the story of where the process broke down. Documents that are often important include the signed consent form, the surgical scheduling request, the pre-procedure verification checklist, any documentation of site marking and the time-out, the operative report, anesthesia and nursing notes, and the imaging the team relied on.
Comparing these records can reveal whether the error started with a wrong entry in the chart, whether the site was marked, and whether the time-out actually took place. If you suspect a wrong-site surgery, ask for complete copies of your records and write down what you were told before and after the operation while your memory is fresh.
Wrong-Site Surgery and Texas Medical Malpractice Law
In a Texas medical malpractice case, the question is whether the surgeon, other members of the surgical team, or the facility failed to act as a reasonably careful provider would have under the same circumstances, and whether that failure caused harm. Because the Universal Protocol sets out widely accepted safety steps, a wrong-site error often raises hard questions about how the team carried out verification, marking, and the time-out. The surgeon, nurses, and the hospital or surgery center may each share responsibility.
These cases are health care liability claims under Chapter 74 of the Texas Civil Practice and Remedies Code. Under section 74.251, a claim generally must be filed within two years from the date of the breach or from the date the related treatment or hospitalization was completed, and no claim may be brought more than 10 years after the act or omission. Children under 12 have until their 14th birthday. The claimant must give written notice at least 60 days before filing suit, which tolls the deadline for 75 days, and must serve a report from a qualified medical professional within 120 days after each defendant files an answer. Compensation may be available for medical expenses, including corrective surgery, lost income, and pain and suffering, although Texas law limits some noneconomic damages in these cases.
Talk With Davis & Davis About a Surgical Error
Our firm focuses on medical malpractice, including surgical errors in Houston and across Texas. We review consent forms, operative reports, and surgical safety documentation with qualified medical professionals to determine whether the care met accepted standards. Every case is different, and we cannot promise a particular result.
If you believe you or a family member had surgery on the wrong site, the wrong procedure, or surgery meant for someone else, contact Davis & Davis to request a free consultation and learn more about your options.
Source: NIH.gov, “Wrong-site surgery: A preventable medical error“, Deborah F. Mulloy and Ronda Hughes, accessed Feb. 16, 2015
Frequently Asked Questions About Wrong-Site Surgery
What is considered wrong-site surgery?
Wrong-site surgery is an operation on the wrong body part, the wrong side, or the wrong level of the spine. Patient safety groups usually group it with wrong-procedure surgery, where a different operation is performed than the one planned, and wrong-patient surgery, where a procedure is performed on the wrong person.
How common is wrong-site surgery?
A frequently cited study estimated about 1 error in every 112,000 operating-room procedures. That figure leaves out outpatient and other procedure settings, and federal patient safety researchers note that counting those settings may raise the rate significantly.
What is a surgical time-out?
A time-out is a planned pause immediately before a procedure begins. The whole team confirms the patient’s identity, the procedure, and the site, and anyone in the room can raise a concern. It is the final step of the Universal Protocol, after pre-procedure verification and site marking.
Who can be held responsible for a wrong-site surgery?
Depending on the facts, responsibility may rest with the surgeon, other members of the surgical team, or the hospital or surgery center whose policies and staff were supposed to verify the patient, procedure, and site. A review of the records by a qualified medical professional helps identify where the process failed.
How long do I have to file a wrong-site surgery claim in Texas?
Under Texas Civil Practice and Remedies Code section 74.251, a claim generally must be filed within two years from the date of the error or from the completion of the related treatment, and no later than 10 years after the act or omission. Because notice and report requirements also apply, it is wise to speak with an attorney promptly.
