[Wrong site surgery : Incidence, risk factors and prevention]

Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been declared by the World Health Organization to be a "never event".

A selective search of the PubMed database using the MeSH terms "wrong site surgery", "wrong site procedure", "wrong side surgery" and "wrong side procedure" was performed.

The incidence of wrong site surgery has been estimated at 1 out of 112,994 procedures; however, the number of unreported cases is estimated to be higher. Although wrong site surgery occurs in all surgical specialities, the majority of cases have been recorded in orthopedic surgery. Breakdown in communication has been identified as the primary cause of wrong site surgery. Risk factors for wrong site surgery include time pressure, emergency procedures, multiple procedures on the same patient by different surgeons and obesity. Check lists have the potential to reduce or prevent the occurrence of wrong site surgery.

The awareness that to err is human and the individual willingness to recognize and prevent errors are the prerequisites for reducing and preventing wrong site surgery.