The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Wrong-site procedures are considered never events, yet they continue to occur. This review describes the incidence, impacts, and contributing factors of wrong-site nerve blocks. The authors recommend verifying the procedure and patient with multiple sources of information, using visible site markings, and employing time outs immediately prior to anesthetic use. A WebM&M commentary discussed an incident involving a wrong-site nerve block.

Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Excisional skin cancer surgery is a common procedure often performed many days after an initial biopsy by a different physician, making it particularly vulnerable to wrong-site surgery. This study provides a range of consensus recommendations for medical professionals and patients to reduce such risks.

This study found that wrong-site surgeries continued to occur despite adoption of "Sign Your Site" initiatives and implementation of a Universal Protocol. The most common errors reported were related to wrong-level spine surgery.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

This review summarizes the epidemiology and common etiology of three types of surgical never events and makes recommendations to prevent such incidents.

This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.

This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.

Wrong-site surgeries are considered rare but devastating never events. However, a recent article suggested that wrong-site procedures may be more common than previously thought, since such errors can occur in procedures performed in areas other than the operating room. This study sought to evaluate the incidence of wrong-site surgery in pain management, using data from 10 facilities over a 2-year period. Although the overall incidence was low—only 13 cases were found with minimal associated patient harm—most cases were considered preventable, as clinicians failed to follow recommended preventive measures. A wrong-site surgery near miss is discussed in this AHRQ WebM&M commentary.

Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.

This case presentation describes a wrong-site surgery incident, provides perspectives from the patient, clinician, and includes reader responses to the case.