Wrong Site

To most people, the thought of a surgeon operating on the wrong site seems like an unconscionable mistake; a report was recently in the media of a wrong kidney removed from a man at Mt. Sinai hospital in New York. However, wrong site surgery is the second most common sentinel event reported to the Joint Commission. Surgery involves many steps, including pre-operative evaluation, consent, scheduling OR time and communication between perioperative personnel, all of which may fail. In addition, some procedures are at higher risk. Spinal surgeries can be especially risky as the patient is often positioned differently than he was during pre-op evaluation and radiographic study.

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