What Are the Biggest Wrong-Site Surgery Risk Factors?

Published on August 14, 2023

We’re at our most vulnerable and trusting when we’re put to sleep for surgery, expecting to be in the best hands of medical professionals who prioritize our well-being. If you’ve never been in the position to wake up from this sleep only to find that your trusted surgeon performed surgery on the wrong body part, you can only imagine the horror and sense of violation you might feel. Sadly, this occurs an estimated 40 times per week in hospitals and surgical centers across the U.S. 

Despite medical literature referring to wrong-site surgeries as “never events,” these egregious errors made up 6% of the 1,441 sentinel errors reported by the Joint Commission. A “sentinel event” is a medical mistake resulting in patient death, permanent harm, or severe temporary harm. Because reporting sentinel events is not mandatory, it’s likely that the statistics underestimate the severity of the problem.

Wrong-site surgery is a completely preventable medical mistake, occurring in about 1 out of every 112,994 surgical procedures despite the strict universal protocols in place to prevent these appalling incidents.

What is Wrong-Site Surgery?

 Wrong-site surgery is a generic medical term with multiple meanings including:

• Surgery performed on the wrong body part
• Surgery performed on the wrong side of the patient
• Surgery performed on the wrong patient, or
• The wrong surgery performed on the correctly identified patient and body site

While some wrong-site surgeries directly result from the surgeon’s actions alone, the majority of these sentinel events occur due to multiple failures in the organizational process of the administrative system and surgical team.

What Safeguards are in Place to Prevent Wrong-Site Surgeries?

The Joint Commission Board of Commissioners created universal protocols in 2004 to prevent wrong-site surgeries in hospitals and surgical facilities. The safety protocol includes three components:

• A pre-operative verification process that’s meant to reveal any discrepancies or missing information before the surgery begins with a focus on ensuring they have the correct patient, correct procedure, and correct site
• A pre-operative marking of the surgical site performed by a licensed independent practitioner who remains present during the procedure
• A “time-out” before the first incision during which all members of the team double-check that they have the correct patient, correct site, and correct procedure

Despite these stringent protocols, wrong-site procedures have not decreased, but instead have risen in numbers since 2004.

Understanding Wrong-Site Surgery Risk Factors

A study released in May of 2023 in the Joint Commission Journal identified significant risk factors and patterns for wrong-site surgeries. The study reviewed 68 cases of wrong-site surgeries between 2013 and 2020. Case numbers were higher in non-ambulatory, in-patient settings compared to ambulatory care facilities. Risks were also higher among specific surgery types including:

• Orthopedic surgeries (35.3%)
• Neurosurgery (22.1%)
• Urology (8.8%)

The most common surgical procedure cited in wrong-site surgery claims include:

• Spine and intervertebral disc surgery (22.1%) often when a surgeon performs a procedure on the wrong disc level
• Arthroscopy (14.7%)
• Muscle/Tendon surgery, especially hand surgery (11.8%)

Failing to follow protocols and failing to review medical records are the top two causes of wrong-site surgeries. Communication problems significantly contribute to this persistent problem.

Outcomes of Wrong-Site Surgeries

Wrong-site surgeries have some of the most serious outcomes found in medical malpractice cases. This preventable injury results in the following outcomes:

• The need for additional surgeries in 45.6% of cases
• Pain in 33.3% of cases
• Mobility dysfunction in 10.3% of cases
• Worsened medical condition in 8.8% of cases, and
• Patient death in 7.4% of cases

While healthcare providers still seek preventative measures to reduce these negative events, for patients who’ve been injured, there is no way to undo the harm. Fortunately, the civil courts offer redress through medical malpractice claims for wrong-site surgeries. A successful claim brings not only financial compensation but also a sense of justice to victims.

Liable Parties in Wrong-Site Surgery Malpractice Cases

While it may seem as though the surgeon is always the liable party in wrong-site surgeries, liability could lie with another party or several parties including other members of the surgical team, the administrative staff, the imaging department, the licensed independent practitioner, or the hospital or facility itself if the surgeon was an employee rather than an independent contractor with surgical privileges. 

Because surgery involves a complex team, it often takes a skilled attorney’s investigation to determine the liable party in a wrong-site surgery case.

Proving Malpractice in Wrong-Site Surgery Cases

Patients who’ve experienced wrong-site surgery may not be able to erase their injuries, but they can seek compensation for their economic and non-economic damages through a medical malpractice case. Proving medical malpractice requires demonstrating proof of liability by gathering evidence to show the following:

• That a doctor/patient relationship existed at the time of the wrong-site surgery
• That the medical provider had a special duty of care to treat the patient at the medical-industry-approved standard of care
• That the medical provider breached this duty of care by acting negligently
• That the negligent breach of duty directly caused the patient’s injury
• That the patient suffered significant damages due to the injury

Once the evidence meets the above criteria, the patient’s medical malpractice attorney can draft a compelling case with the liable party’s medical malpractice insurance to recover compensation for damages. Most claims settle out of court, but some may proceed to a lawsuit.

Common Damages in Wrong-Site Surgery Claims

When a patient undergoes a wrong-site surgery, the mistake almost always requires further medical intervention. Plus, there is often a significant delay before the patient undergoes their originally scheduled surgery. Recovering from multiple surgeries is painful, debilitating, and expensive. It’s also one of the most traumatic medical experiences possible, with lasting impacts on a patient’s emotional health. A successful medical malpractice claim could result in compensation for the following damages:

• Medical expenses
• Future medical expenses for upcoming surgeries, procedures, and treatment related to the wrong-site surgery
• Lost wages
• Future lost wages
• Diminished earning capacity if the medical mistake left the victim with a disability
• Pain and suffering
• Emotional trauma, disfigurement, loss of quality of life

Because patients themselves are unconscious during surgery, it’s impossible to have a plan in place for self-protection. Instead, they rely solely on the surgical team and the process, which has proven fallible. When a patient sustains an injury during surgery due to a preventable error, they’re owed significant compensation for damages. Contact a Phoenix wrong site surgery surgical errors attorney today to learn about your potential legal case for compensation.