Firm-Wide blog

Wrong-site Surgery: A “Never Event”

By Burg Simpson
February 22, 2013
4 min read

In the medical community, some things are known as “never events.” One of these is operating in the wrong place–for example, the patient needs a LEFT knee replaced, and the surgeon accidentally replaces the RIGHT knee, which was healthy before. This phenomenon is known as wrong-site surgery. Wrong-site surgery should never happen with the exercise of reasonable care. Surgery performed on the wrong site is, by itself, evidence of negligence. Wrong site surgery, such as replacing the wrong knee, is always preventable with the exercise of normal caution.

One way this is prevented now is by the surgeon marking on the patient right before surgery. If you’ve had surgery in the last 10 years or so, you may recall your surgeon marking on you with a special surgical marker or pen. This is usually done in conjunction with a few questions they ask you first, such as “what are we operating on today?”

I’ve been to the OR with my own family members a few times, and they all have the same reaction to this question– “oh my god, this doctor doesn’t even know what they’re supposed to be operating on!! I’ve got to get out of here!!!

Whoa, Nelly. Don’t panic!!

What I always explain to my family when this happens is this–yes, the doctor does know what they’re operating on, but they need to hear it from you also, to ensure no one has made a mistake. This is part of a safety checklist system that reduces errors, just like a pre-flight checklist reduces airline crashes.

Your Surgeon (Probably) Isn’t Senile, They’re Preventing Wrong Site Surgery

So, before you jump to a conclusion about your surgeon that isn’t very flattering (i.e., s/he is so busy they can’t remember me for the 30 minutes between when they see me in pre-op until I’m on the OR table, or s/he must have a very bad record of making such mistakes), you should know a couple things about why this is done. First, there has been a good bit of evidence in recent years that such practices significantly reduce errors in the OR–much the same way wearing a seatbelt reduces highway fatalities. Wearing a seatbelt doesn’t make you a bad driver, does it? Surgeons do this so that in the OR, they have a visual reminder of exactly where they’re supposed to be working. They also know that before making that mark, you verbally confirmed that it was the correct site, as did your chart.

The other thing you ought to know is that in the pre-op area, when you see your surgeon, you look like you. They see your face, they talk to you, and you look like a human. In the OR, not so much. By the time your surgeon comes into the OR to begin surgery, you are likely covered with layers of sterile drapes and orange-colored iodine paint, or even self-adhesive plastic sheets. Your face and head will be partially covered and/or only visible to the anesthesiologist, or you may be in a position (i.e., face down) where the surgeon can’t see your face at all. So my point is, you may not look anything like you did in pre-op, and in the interim, since your surgeon signed her autograph on your knee, she may have visited a number of other patients in the pre-op area and signed her name on a few other knees before coming back to you in the OR. Now you want her to remember who needs a right knee and who needs a left knee? Chances are she probably does remember, but wouldn’t you rather be certain?

Safety Checklists and Pre-op Marking Prevent Wrong Site Surgeries

Asking you those questions that seem silly and making that mark on your skin are easy, low-cost ways to substantially reduce the chances of wrong-site surgery. These are good practices that should be encouraged, and have already resulted in a reduction of injuries. Wrong site surgery is preventable through the use of procedures like this, and should never happen with the exercise of reasonable care.

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