June 2007
What You Can Do to Prevent Wrong-Site Surgery
Anesthesiology; Nursing; Surgery


Patients can take a more active role in their healthcare to prevent medical errors—in particular, errors that may occur during surgery, such as a wrong-site surgery. Data received by the Patient Safety Authority shows that a near miss or actual wrong-site surgery occurs every other day in Pennsylvania. However, wrong-site surgeries are 100 percent preventable. In many cases, patients or their family members prevented the error by speaking up. Know what steps you can take to prevent a wrong-site surgery from happening to you or a loved one.  

Real-life Pennsylvania Case

The following is a case of two wrong-site procedures done on one patient because the patient was placed in the wrong position. The patient consented to having his RIGHT Achilles tendon repaired along with a joint on his LEFT hand. The patient was identified, the time out was done, and the surgical sites were marked correctly with the patient lying on his back. The patient was turned to lie on his stomach, which hid the markings from the surgeon’s sight. The procedure was then performed in reverse with the repairs done to the LEFT Achilles tendon and a joint in the RIGHT hand.

What You Can Do to Prevent Wrong-Site Surgery and Prepare for Surgery:

(Additional Source: Agency for Healthcare Research and Quality)

  • Don’t be upset if each doctor or nurse asks the same questions about your identity, procedure, and the side or site of the operation. They are supposed to individually check with the patient rather than accept what someone else has written or said.
  • Make sure that you know which physician is in charge of your care.
  • In addition to your name, give healthcare professionals another identifier, such as your birth date, to confirm who you are.
  • If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done.
  • Speak up if you have questions or concerns.
  • If something does not seem right or if you do not understand something, say so. Ask for an explanation.
  • Ask the doctor or nurse to mark the place that is to be operated upon.
  • Make sure you have someone with you that you trust to be your advocate. This person can ask questions you may not think of and remember important information you may forget.
  • Make sure all health professionals involved in your care know your medical history.
  • Educate yourself about your procedure and don't be afraid to get a second opinion.

For more information on wrong-site surgery, go to the Authority's website at www.patientsafetyauthority.org and click on "Browse by Topic," then "Event" and type in "wrong-site surgery" or click here. The Authority has been working continuously on preventing wrong-site surgery since the first Pennsylvania Patient Safety Advisory article was published  in June 2007.

©2018 Pennsylvania Patient Safety Authority