Wrong site surgery: A study of 664 events from 237 facilities across a 10-year period (20 February 2026)

Summary

Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” This avoidable medical error continues to be significant problem in hospitals and ambulatory surgical facilities (ASFs).

Expanding on previous WSS research, the authors of this study took a novel approach and reviewed and analysed 644 WSS events reported in Pennsylvania from 2015 to 2024 and identified combinations of clinically related variables, such as type of facility, hospital procedure location, error type, clinician specialty, region of the body, and specific procedure. Most of these WSS events occurred in hospitals rather than ASFs, distributed across operating rooms, interventional radiology, and other procedural locations. The most frequently involved specialties were interventional radiology, pain management and orthopaedics.

This study represents one of the largest samples of WSS events examined in a single study. The authors have visualised their deep-dive analysis in 16 figures, tables, and supplemental appendices to help stakeholders comprehend the many combinations of variables contributing to WSS, identify these factors in their own facility, and design interventions to improve patient safety.

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