Practice of Medicine


Case Study: Wrong Site Surgery

By: Hall B. Whitworth, Jr., MD

A 49-year-old man underwent a colonoscopy by a colorectal surgeon who identified a large, firm tumor causing partial narrowing, approximately 60-70 cm from the entry site. Pathology of this tumor was suspicious for carcinoma. In addition, a polypectomy was performed at a different location, and the site was tattooed. Pathology of this second site was consistent with tubulovillous adenoma.

Two weeks later, the same surgeon performed a partial colectomy of the tattooed area, believing it to be the marker for the tumor to be removed. On further consideration, after the procedure, the surgeon reviewed the colonoscopy and pathology reports and realized the wrong portion of the colon had been removed. The surgeon discussed this with the patient and family, and two days later a second surgery was performed. The patient initially did well after this second procedure, but on the 10th day, an anastomotic leak was discovered by barium enema. A third procedure was performed, finding adhesions and a severe inflammatory reaction which required a diverting loop ileostomy on the right side of the abdominal wall. One day after hospital discharge, the patient was readmitted for 2 days due to fever, abdominal pain, and bloody drainage.

Over the course of the next month, the patient had 3 separate ED evaluations for complaints of fever, dyspnea, weakness, and cough with continued antibiotic treatment for a diagnosis of bacterial pneumonia. An oncology consultation was obtained 10 weeks after the initial surgery.  Instead of chemotherapy, the oncologist recommended observation. After several surgical follow-up visits, the patient underwent closure of his ileostomy almost 7 months after surgery. Within 10 days after this closure, however, the patient was again seen in the ED with fever and redness at the closure site. Cultures were positive, and the patient was once again admitted, this time with a right lower quadrant abdominal abscess requiring incision and drainage. Two months later, the patient was noted to have metastatic cancer involving the liver, and an intravenous port was placed to facilitate chemotherapy. 

Despite focused attention and protocols, provider preventable patient harm continues to be a problem. Examples can include wrong site or wrong procedure surgery, and retained objects.  Researchers from Johns Hopkins reported an analysis of data from the National Practitioner Data Bank suggesting these events may occur in the United States at least 80 times per week. Patient safety in surgery can be influenced by decision based errors, including inadequate knowledge, mistakes in judgment, or cognitive bias. Often, however, communication errors may be an important cause of adverse events. Another study found that almost one-third of operating room communication resulted in partial failure, such as poor timing, missing or inaccurate information, or failure to resolve an issue. 

Several approaches are recommended in an attempt to reduce risk and improve communication:

  • Preoperative initial timeout to review informed consent and confirm patient identity, planned surgical location, and procedure. This should include the patient or surrogate, at least two medical professionals and be documented in the medical record
  • In the operating room, implement a timeout with the entire team to review patient identity, review diagnostic studies, and confirm the planned surgical site and procedure again
  • Standardized checklist as a cognitive aid to ensure necessary information and safety measures are available. This may include a surgeon-led, pre-operative briefing outlining the surgical plan, anticipated intra operative needs (equipment, blood, etc.) and risks
  • Techniques to reduce distractions and interruptions. Limiting extraneous personnel in and out of the room, reducing the noise level, assigning coverage for beeper calls, and limiting extraneous interruptions to the surgeon to only time-sensitive, vital issues
  • At the completion of the procedure, a formal debriefing may include review of any equipment or supply concerns, correct processing of any pathology samples, and arrangements for transition and handoff of post-operative care
  • Consistent utilization of a preoperative review of the surgical plans, standardized checklists, and continued open communication throughout the team may help to further reduce the risk of surgical adverse events



Surgery. April 2013;153(4):465

Annals of Surgery. 2011;253:849

Quality & Safety in Health Care. 2004;13:330


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