Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events

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Abstract
Performing a procedure on the wrong side of a patient's body, performing a wrong procedure, or performing the correct procedure on the wrong patient constitute some of the worst medical errors that clinicians and patients experience. The Institute of Medicine report To Err Is Human painted a broad picture of the magnitude of medical errors in the United States and gave directions for safety improvements.1 Questions linger about ways to prevent errors such as wrong-side surgery. Although these events seem preventable, they continue to occur. We have few data on how often and why they occur and on why the safety mechanisms in place fail to prevent them. This report presents data demonstrating that there are many more wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) than generally appreciated. The data indicate that current practices and guidelines for WSPE prevention are insufficient to prevent future events.

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