A surgical procedure may occur at the wrong site if the health care provider confuses a patient's left and right sides, or if the person preparing the patient for surgery selects the wrong side by accident. This can result in very serious errors, especially with amputations, ocular enucleations and the like.


Risk factors:

(1) A person with a disease affecting both left and right sided sites (legs, knees, wrists, eyes, etc.)

(2) The surgeon is not involved in patient preparation and arrives after the prep has been completed.

(3) Insufficient information (medical records, imaging studies, etc.) is available to document the correct site.

(4) Both left and right sites are either externally normal appearing or equally affected.


Methods for reducing wrong site surgery:

(1) Have the operative site clearly marked with an indelible marker while the patient is unsedated. This may be done at the time of informed consent. The person making the mark should initial the site. A witness is recommended.

(2) Have all members of the surgical team verify the correct site in the operating room prior to starting the case.

(3) Cross-check the operative site with the medical record documentation (consent form, imaging reports, surgeon notes, etc.) and operating room records.


If a discrepancy is noted, then the case should be delayed until verification can be obtained.


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