Wrong-site surgery (performing surgery on the wrong side, wrong body part, wrong patient, or using the wrong prosthesis) is very rare, but is the most common surgical mistake. And, at least in theory, it should be easily avoided.

Ten years ago I was the RANZCO representative on a multi-disciplinary Queensland Health committee that developed Queensland Health’s correct site surgery policy and protocol. This was quite educational because around the world there are a variety of protocols that attempt to prevent this complication, and not all of them work. Some are too complicated, which means people in busy hospitals may skip steps or make errors in following the policy itself. 

One research paper in the Archives of Surgery found that the incidence of wrong site surgery was less than 1 in 100,000 operations, and that most of these did not result in significant problems, but that existing protocols would only have avoided about two thirds of these. Protocols were often too complex and ineffective.

In Queensland there are 4 steps: identify the patient, check informed consent, mark the site with the patient awake, and a final check in which surgeon, scrub nurse and anaesthetist check patient, side, planned operation and prosthesis before starting.

For patients this constant checking and double-checking can be a bit tedious, but this is a simple and pretty quick way of eliminating this avoidable error.


MR Kwaan et al.Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006 Apr;141(4):353-7; discussion 357-8.