Could Better Communication Prevent Wrong Site Surgery?

One element of surgical errors that seems – on the surface – easy to prevent is the notion of wrong-site, wrong-procedure and wrong-patient surgeries. Often abbreviated as WSPE, this form of negligence can lead to life-changing medical errors such as the removal of a healthy organ or the amputation of the wrong limb. Various root cause analyses of WSPEs highlight a prominent underlying factor that can prove deadly to thousands of patients each year.


Few anecdotes are told with the vivid detail and terrifying implication of “don’t let this happen to you” as a WSPE. Having the wrong extremity amputated or the wrong internal organ operated on can be among the most frightening of all medical errors. In fact, among WSPEs, patients who have similar names might find themselves involved in a wrong-patient procedure – a living nightmare for the medical professional and patient alike.

Improved communication between the medical staff members as well as between patient and surgeon can have a dramatic impact on the number of errors suffered. Many facilities are employing tactics such as site-marking and timeouts.

  • Site-marking: Many facilities have started encouraging surgeons to “sign your site” in an effort to remove any ambiguity prior to a procedure. The participation in the initiative varied between hospitals and specialties. Additionally, inconsistent direction often led to ambiguity – is the site marked to be operated on, or to be avoided?
  • Timeouts: In an effort to adhere to a Universal Protocol, one element that has gained prominence is the use of pre-surgery timeouts. This planned pause, a surgical timeout, gives all involved personnel the time needed to review the procedure, answer any team questions and address any lingering ambiguity well before an invasive surgery is started.

With the added emphasis on communication, medical facilities and surgeons hope to reduce the incidence of WSPEs. Patients who have suffered through the aftermath of a surgical error understand the devastation that follows. Loss of a healthy limb, incorrect surgery on a healthy organ … this negligence can lead to a lifetime of pain, physical therapy and additional surgeries to correct the initial surgical error.

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