A universal protocol for prevention of wrong site surgery has been in place for over 10 years. Despite this widely adopted protocol, wrong site surgery still occurs, as many as 2,700 cases each year. In addition there are many more near misses that are corrected moments before an incision is actually made. Wrong site surgery is considered a “never event” because it should never happen and is a risk of surgery that a patient should never have to accept.

Ongoing cases of wrong site surgery are due to inconsistent practice or lack of participation in the established protocols to prevent a mishap. Wrong site surgery can be on the wrong patient, wrong body part, wrong side of the body or wrong level of an anatomic site, such as the spine. Most wrong site surgery is wrong side surgery.

So what can be done to prevent wrong site surgery? The best way is to have the patient confirm the surgical site as the surgeon marks it. One should carefully review the operative consent form before signing. Also it is very important that there be a “time out” in the operating room to verify the correct patient, correct procedure and correct site, requiring the participation of the entire OR team.