Vivid and terrifying

What is Wrong Site Surgery?

Wrong site surgery (WSS) refers to surgery at the wrong site, surgery on the wrong side, performing the wrong procedure, and/or surgery on the wrong patient. It is widely accepted that WSS is a preventable event that should never occur. WSS may result in permanent injury to the patient, damaged reputations for the surgeon/surgical facility, and significantly elevated medicolegal risks.1 


Boy Eye Wrong Site Surgery

"Eye surgeon’s error confounds boy’s parents. She mistakenly operated on the wrong one; lawsuit being mulled."
Read more at The Columbian.

Wrong Site Surgery

"He underwent surgery to remove his right testicle. When he woke up, his left one was missing."
Read more at The Washington Post.

Sleeping Baby Image

"Mix-up leads to surgical procedure on wrong baby."
Read more at CBS News.

Historical attempts to eliminate Wrong Site Surgery

American Academy of Orthopaedic Surgeons


In 1998, American Academy of Orthopedic Surgeons (AAOS) launched the Sign Your Site campaign, a movement that encourages surgeons to clearly mark their initials on the correct site as part of their pre-operative routine in order to reduce errors.2

The Joint Commission Logo


In 2004, the Joint Commission introduced a Universal Protocol that provides guidelines for the fundamental elements of a WSS prevention protocol. The Universal Protocol includes requirements for marking of the surgical site, confirmation of patient identity, confirmation of the intended procedure, and review of these details among the surgical team during a final time-out immediately prior to the start of surgery.1

World Health Organization Logo


In 2008, the World Health Organization (WHO) advanced the "Safe Surgery Saves Lives" initiative that included the WHO Surgical Safety Checklist, a 19-item tool created by WHO in association with the Harvard School of Public Health.3

Wrong Site Surgery continues to occur

While Sign your Site, Universal Protocol and WHO Surgical Safety Checklist guidelines are specific in content, form of implementation can vary widely across hospitals and surgery centers. Even when WSS prevention protocols are implemented, adherence to such protocols may not be consistent within a given system. These factors may help to explain why, although WSS seems entirely preventable, WSS continues to occur and has not declined since the implementation of the Universal Protocol.4 In fact, the number of events reported to the Joint Commission have trended upward since 2005, after the implementation of the Universal Protocol.5



Learn More about the StartBox Patient Safety System.


1. Agency for Healthcare Research and Quality. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Accessed 3/13/2018.
2. Jack's Daily Dose. Sign your Site Campaign. Accessed 3/13/2018.
3. World health Organization. Safe Surgery: Why Safe Surgery is Important. Accessed 3/13/2017.
4. James MA, Seiler JG, 3rd, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am. 2012;94(1):e2(1-12). 
5. The Joint Commission. Sentinel Event Data Summary, February 23, 2018. Accessed 3/13/2018.

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