Understanding Wrong-Site Surgery
Wrong-site surgery is classified as a “never event” — a serious, preventable medical error. This page provides educational background on what it is, how often it occurs, and what patients should know.
What Is a “Never Event”?
The term “never event” was introduced by the National Quality Forum (NQF) to describe serious, largely preventable patient safety events that should never occur in a well-functioning healthcare system. Wrong-site surgery is among the most recognized never events.
Examples of surgical never events include:
- Operating on the wrong side of the body (e.g., left vs. right)
- Performing surgery on the wrong body part or organ
- Performing a procedure on the wrong patient
- Performing a completely different procedure than planned
- Leaving a foreign object inside a patient during surgery
Wrong-Side vs. Wrong-Site vs. Wrong-Procedure
These terms are often used interchangeably but have distinct meanings:
Wrong-Side Surgery
Surgery performed on the correct body part but on the incorrect side of the body — for example, operating on the left knee when the right knee required surgery.
Wrong-Site Surgery
Surgery performed at an incorrect anatomical location — for example, operating at the wrong spinal level during back surgery.
Wrong-Procedure Surgery
A procedure performed that was not the one consented to or intended — for example, performing a knee replacement when only a minor procedure was scheduled.
Wrong-Patient Surgery
A surgical procedure performed on a different patient than the one for whom it was intended — often due to patient identification failures.
How Common Is Wrong-Site Surgery?
The following figures are derived from publicly available medical studies and government reports. They are estimates and may not reflect the most current data.
Reported Weekly
Estimated wrong-site surgeries reported in the United States per week, based on available safety data.
Per 100,000 Procedures
Estimated incidence rate across all surgical specialties. Exact figures vary by study and reporting methodology.
Average Settlement (Est.)
Reported average settlement figure from published research. Actual outcomes vary greatly depending on case specifics.
Under-reporting is believed to be significant. Many wrong-site events may go unreported or are settled privately, meaning true prevalence is likely higher than official figures suggest.
Most Commonly Affected Surgical Specialties
Based on published research and voluntary reporting databases, wrong-site surgeries appear most frequently in the following specialties (approximate figures):
Orthopedic Surgery
The most commonly reported specialty, including knee, hip, and extremity procedures.
Neurosurgery
Particularly spinal surgery, where operating at the wrong vertebral level is a documented risk.
Urology
Errors involving paired organs such as kidneys represent a known risk category.
Other Specialties
Including general surgery, thoracic, vascular, and others. No specialty is immune.
Figures are approximate estimates from published research. Sources include voluntary reporting systems which may reflect under-reporting.
Frequently Asked Questions
How does wrong-site surgery happen?
Wrong-site surgery most commonly results from failures in the pre-operative verification process — such as incorrect site marking, inadequate patient identification checks, or breakdowns in the surgical team's time-out protocol. The Joint Commission's Universal Protocol was established to prevent these errors.
Can hospitals prevent wrong-site surgery?
Yes. Standardized protocols such as surgical site marking, pre-operative checklists, and mandatory team “time-outs” before incision are designed to prevent these errors. When hospitals fail to follow these protocols, they may bear responsibility for resulting harm.
What should I do if I think I experienced wrong-site surgery?
First, address your immediate medical needs. Then collect all records related to the procedure. Consider speaking with a licensed medical malpractice attorney in your state to understand your rights and options. Time limits apply, so do not delay.