Surprisingly few peer-reviewed papers on the subject of wrong-sided surgery appear in the electronically indexed medical literature. Use of the key phrases “wrong side,” “wrong sided surgery,” “incorrect side,” “erroneous side,” “sidedness error” and “right–left error” in PubMed yielded fewer than 10 English-language papers,2,3,4,5,6,7,8
1 German paper9
and 3 single case reports in Swedish with no authors listed. However, it is very likely that this type of error is underreported for obvious reasons. Of the large chart reviews that elevated the profile of error in medicine since the early 1990s, the largest to deal with primarily surgical adverse events reported on 15 000 charts, and wrong-sided surgery is not mentioned in that paper.10
The introduction of “wrong-side surgery” in most popular search engines on the Internet yields on the other hand about 288 000 Web sites, some of which are quite useful, focusing on prevention of this error.11
Of the few reports available, 2 described erroneous laterality marking on CT scans2,9
and 1 on chest films.4
At least 2 others report wrong-sided chest tube placement.3,6
Another chronicles a small number of wrong-sided anesthesia blocks in a series of 2000 incident reports regarding regional anesthesia in an incidence-monitoring study.5
The 3 Swedish papers are 25 years old and apparently described reports of surgery on the wrong femur, hip and ureter. Some papers address policies used to safeguard against this preventable adverse event and record the usefulness of the simple act of marking sides.6,8
Human error is an inherent part of human behaviour and will always be present. Certain factors may predispose to increased frequency of human error in surgery, such as fatigue, which is common in surgeons and their housestaff and has been shown to increase error.12
Distractions and competing responsibilities to other patients with more urgent conditions may also contribute to errors13,14
as may imperfect communication in the operating room.15
However, the modern approach to patient safety and error prevention focuses on a systems approach as opposed to human error.16,17
If systems are in place that make it impossible for human error to reach the patient and cause harm, patient safety will be markedly improved.
If one examines the error of wrong-side surgery from a systems approach, simple, commonsense low-technology strategies to put systems in place could start with preoperative discussion between the surgeon and the family or patient, review of the patient's chart, and then side-marking on the appropriate body part. For example, for lumbar discectomy, the author marks the correct side with a large black marker on the ipsilateral buttock. This is not visible after the patient is draped, but the surgeon and the surgical team have had to think about and discuss the correct side before the mark can be placed. Such a policy has already been demonstrated to reduce the incidence of wrong-side knee surgery.18
These systems are not fail-safe since poor communication can occur between surgeon and patient, and the surgeon can still have a lapse in concentration when marking the side or when the surgical drapes are placed. A simple back-up would be for the charge nurse in the operating room or the anesthetist, or both, to discuss the side with the surgeon and fill out a check-list before the incision is made.
More high-technology and fail-safe systems for preventing wrong-side error exist. In cranial neurosurgery, if every craniotomy were done with the aid of a surgical navigation system registered to current imaging19
or in an intraoperative magnetic resonance imaging unit,20
the occurrence of wrong-side craniotomy would be decreased from rare to almost never. These surgical adjuncts are commonplace in most modern neurosurgical units, but they are often not available after hours and therefore they may not prevent an error like the one described here.
Systems must be developed to ensure maximum patient safety and minimize preventable adverse events. Widespread attention to medical error and its prevention is becoming part of the culture in most health care organizations. Wrong-sided surgery is fortunately rare, but when it does happen it is devastating for the patient and the care-givers, and should almost be considered the archetypal surgical error type in which simple but intelligent systems approaches should be able to reduce its incidence to zero in all types of surgery.