Written by

Iain Dodd - Partner, Senior Solicitor

Wrong site surgery can have devastating effects for patients, it is therefore extremely important that steps are taken in order to reduce the amount of wrong site surgeries that occur. In this article we will be discussing what wrong site surgery is and how to prevent it. 


What is wrong site surgery?

Wrong site surgery comes under the term Never Events, and as stated by the NHS, “Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” 

Wrong site surgery is a preventable error that can occur during surgery, the term includes errors such as the wrong surgery being performed, the wrong patient, wrong side or wrong surgery side. According to the NHS, wrong site surgery is “an invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb). The incident is detected at any time after the start of the procedure.” 

Patients that have experienced wrong site surgery are at risk of developing further health complications and further injuries. 


How to prevent wrong site surgery 

Wrong site surgery should never happen and the NHS has released a document on how they can learn from previous wrong site surgery cases and ensure that they don’t happen again. These preventable measures include:

  • Ensuring all patients have a clinical assessment by the surgical team that is well documented before the surgery 
  • Making sure that surgery is not planned without using the patients notes
  • Ensuring that there are no abbreviations used when writing down left and right, it needs to be clearly written so that it is understood by everyone involved in the surgery
  • Making sure a surgical checklist is carried out before the surgery starts and the people operating must participate in the final checklist before they start operating
  • When going through the surgery checklist, the site of surgery should be said out loud 
  • Ensuring the procedure and site of procedure is displayed so that it is visible for everyone in the theatre
  • Making sure that the correct procedure is on the theatre system and that it is correctly coded into the system
  • Ensuring that there is always indelible ink surgical parker pens available everywhere in the hospital so that the ink is not wiped off 
  • Making sure the site is always marked before giving the patient any anaesthesia 
  • Making sure that the person operating is the person who is marking the site if possible 
  • Ensuring that the person who marks the site of surgery is present for the start of surgery and is participating in the checklist 
  • If the patient is face down, there is a greater risk for error so it is important that everyone involved in the surgery takes more care
  • Error provoking conditions can arise when surgeries are moved to different theatres where there are different layouts to where the surgeon usually operates, so again, it is important that more care is taken and all of the necessary steps are thoroughly carried out
  • Anyone who is arriving late to theatre must be briefed about the procedure and read the procedure notes 
  • If people are late for their theatre slots, timetables and commitments should be reviewed and changed accordingly, this is because being pressured for time can cause shortcuts and errors

All of these steps should be taken in order to prevent wrong site surgery and to ensure that all surgeons are providing the best possible care to their patients.  


Wrong site surgery statistics 

According to the NHS Resolution, between the 1st April 2022 and 31st March 2023, there were a total of 384 Never Events, and 169 of these were wrong site surgery. The highest number of claims were relating to: 

  • Wrong site block – there were a total of 40 occurrences 
  • Wrong skin lesion removed – there were a total of 24 occurrences
  • Injection to wrong eye – there were a total of 8 occurrences

For the financial year 2021/22 there were a total of 54 claims relating to wrong site surgery and this cost the NHS a total of £10,354,200. 


Wrong site surgery claims 

Wrong site surgery can have devastating effects for patients including physical and mental wellbeing implications, and financial implications. Surgery is an extremely delicate procedure and if things go wrong, there can be devastating effects and knowing that it could have been prevented if the necessary steps were taken can be even worse. Operating on the wrong area of the body can have direct consequences on the patient’s overall health and if you have been operated on the wrong site, you may be able to claim for compensation. You may be able to claim in the event of: 

  • General surgery being performed in the wrong site 
  • Further health complications due to wrong site surgery 
  • Existing symptoms becoming worse due to wrong site surgery 
  • The unnecessary removal of an organ
  • Amputation of the wrong body part

If you believe you have suffered any form of wrong site surgery, contact Patient Claim Line today and one of our medical negligence experts will be able to guide you through your claims process.

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