Factors Increasing the Risk of Wrong Site Surgery
Surgeon running multiple rooms is the factor that increases the risk of wrong site surgery. 1
Risk Factors for Wrong Site Surgery
Wrong site surgery (WSS) is a preventable adverse event that should never occur but continues to happen in surgical practice. Several factors have been identified that increase the risk:
Surgeon running multiple rooms simultaneously is a significant risk factor as it creates time pressure, divided attention, and potential for confusion between cases 1, 2
Surgery performed under unusual time pressure or emergency conditions increases the risk of wrong site surgery by limiting proper verification procedures 3, 4
Fatigue among surgical team members has been recognized as a contributing factor to wrong site surgery 3
Unusual patient anatomy can lead to disorientation and wrong site identification, particularly in spine surgery 3
Failure to verify the operative site by radiography (particularly in spine surgery) is a common contributor to wrong site errors 3
Breakdown in communication among surgical team members is identified as the primary cause of wrong site surgery 4
Multiple procedures on the same patient performed by different surgeons increases the risk of confusion 4
Prevention Strategies
The following evidence-based strategies can help prevent wrong site surgery:
Implementation of a formal timeout process with structured closed-loop communication where information is stated and verbally confirmed by all team members 1
Explicit description of procedure and operative site on informed consent forms without using abbreviations 1
Preoperative verification by nursing staff asking the patient which site is to be operated on before administering any medications 1
Surgeon discussion with the patient about the planned procedure and marking of the appropriate site 1
Availability of office chart notes in the operating room for reference during the procedure 1
Visible display of the operative plan where the surgeon can read it while gowned and gloved 1
For bilateral sites, use of standardized coding (Right=1, Left=2, Bilateral=3) 1
Common Pitfalls
Several pitfalls can undermine wrong site surgery prevention efforts:
Performing patient positioning and anesthesia interventions before completing the timeout process can lead to errors 2
Failure to verify consents or site markings properly is a common contributor to wrong site surgery 2
Improper execution of the timeout process can render it ineffective - 31 formal timeout processes were documented as unsuccessful in preventing wrong surgery 2
Variable marking practices across specialties - while orthopedic surgeons typically mark before surgery, some urologists and ophthalmologists report not doing so 5
Lack of formal hospital policies specifically addressing wrong site surgery prevention 5
Inconsistent methods used to mark patients across different practitioners 5
The evidence clearly shows that having a surgeon run multiple operating rooms simultaneously is a significant risk factor for wrong site surgery due to the divided attention and increased time pressure, which can lead to communication breakdowns and verification failures 1, 2.