While coverage of wrong-side, wrong-site, wrong-procedure, and wrong-patient surgery occasionally appears in the lay press, it has been virtually nonexistent in the medical literature. Using four separate databases, including the National Practitioner Data Bank, a new study estimates that such events occur 1,300-2,700 times a year in the United States (Arch Surg. 2006;141:931-939). This is 20 times more common than previously thought and suggests that current prevention efforts may be inadequate.


In 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required a three-step process for preventing patient, procedure, or surgical site errors. Steps included an operating room “time-out” to verify the patient’s identity, confirm the procedure to be performed, and ensure that all necessary equipment was present. But because the JCAHO does not require reporting of errors, there is no way to tell if the policy is working.

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The study’s authors recommend making the reporting of these events mandatory. This would enable careful analysis of cases to prevent future occurrences. Prevention requires innovative technologies (including bar-coding to identify patients), reporting of case occurrence, and learning from successful safety initiatives (such as those undertaken in transfusion medicine and other high-risk nonmedical industries), while reducing the shame associated with these events