Surgical Errors: Wrong Site, Wrong Patient, Wrong Procedure Expert Article

The common sentinel events in surgery involve the wrong site, patient, and procedure errors. In this article, nurse practitioner Rebekah Price discusses the standard of care for preventing surgical errors. 

Sentinel Event Surgical Error Expert Witness Investigations

Surgical Errors: Wrong Site, Wrong Patient, Wrong Procedure 

A “Never Event,” also known as a sentinel event, is an unexpected occurrence involving severe physical/psychological injury or death. These types of preventable events trigger an immediate investigation by the organization and are publicly reportable. They require review by The Joint Commission, the peer review organization responsible for the accreditation of health care facilities. 

Due to the devastating effects of these preventable events, health care organizations are under increasing pressure to eliminate them. 

Some of the most common surgical never events include:

  • Wrong Site – incorrect body part, wrong side of the body, or wrong level of anatomically correct side
  • Wrong Patient – patient misidentification
  • Wrong Procedure – inconsistent with the correctly documented informed consent for the patient

These never events can devastate the patients, families, health care providers, and facilities involved. Root cause analyses of these sentinel events have exposed systematic problems with these preventable errors, with the main contributor being communication breakdown.

These communication failures can happen during the preoperative, intraoperative, or postoperative phases. Oftentimes, there is a lack of a formal system or a breakdown in the current system for surgical verification. These communication breakdowns are fundamental barriers to safe and effective patient care.

The Joint Commission established its National Patient Safety Goals (NPSGs) program in 2002 to assist accredited organizations in addressing specific concerns and improving patient safety. These NPSGs have been updated and expanded upon annually.

Included in these National Patient Safety Goals are: 

  1. To improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures. 
  2. To eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents and to implement a process to mark the surgical site and involve the patient/family.

Who is at fault when known sentinel events occur? 

It can be multiple parties: the surgeon, any member of the surgical team, and/or the facility where the procedure took place. The interdisciplinary nature of work in the surgical environment relies on cooperation upon every link in the surgical team chain, all working together in a collaborative effort to ensure patient safety and avoid errors. 

Investigating Surgical Errors

When properly implemented, the Universal Protocol, promulgated by the Joint Commission, is effective at curbing surgical never events. Expert witness investigations into these incidents will often seek to understand the manner in which the three successive steps were implemented: 

  1. Conducting a pre-procedure verification process – This confirms the correct procedure, the correct patient, and the correct site. It also addresses missing information or discrepancies before starting the procedure.
  2. Marking the procedure site – This should be done in correlation with the consent form, marked by the surgeon performing the procedure, collaborating with the patient who is alert and awake (pre-sedation), and marked with an indelible marker that won’t wipe away easily. 
  3. Performing a time-out – This is a brief pause by the entire surgical team before the initial incision to confirm the correct patient, procedure, and site. Is the patient placed in the correct position? This involves verbalizing and documenting the time out that was completed. Any team member can call an additional “time out” if there is confusion or discrepancy.

Some Discovery Questions to Consider:

  • Was the time-out performed adequately?
  • Were the consent forms filled out thoroughly and adequately before surgery?
  • Was there adequate staff-staff communication during handoffs & transition of care?
  • Were the policies adequately implemented?
  • Was there adequate communication of relevant patient information?

Additional items for expert review may include staffing and scheduling records, training policies and documentation, and the facility’s communication protocols.

Health Care Expert Witness Investigations

The experts at Robson Forensic are qualified to investigate a broad range of issues relevant to surgical incidents, including preoperative, intraoperative, and postoperative phases of patient care.

For more information, submit an inquiry or call us at 800.813.6736.

Featured Expert

Rebekah Price, Doctor of Nursing Practice & Health Care Expert

Rebekah Price, DNP, MSN, APRN, FNP-C

Doctor of Nursing Practice & Health Care Expert
Dr. Rebekah Price is a Board-Certified Family Nurse Practitioner and Registered Nurse with nearly 20 years of experience in patient care and regulatory compliance. She has hands-on experience in… read more.


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