From The Ergoweb® Learning Center

Wrong Surgeries Guesswork Impedes Way Forward

At graduation most doctors in the United States swear to the ancient Hippocratic Oath. It says, in so many words, “Above all, do no harm.” The oath isn’t always treated with reverence in the operating room. Surgeons are known to remove the wrong limbs or organs, slice into the wrong side of bodies and perform surgery on the wrong patients. Errors like these may or may not be rare because the numbers are guesswork: doctors are not given to advertising their mistakes and many states do not require hospitals to report the blunders. 

In October the Washington Post told of a patient who had his sole functioning kidney removed and of a stroke survivor who was supposed to undergo circumcision but had his testicles removed instead. 

Medical watchdogs, federal agencies and other interested parties agree that even one such case is too many, but there is no consensus on the scale of the problem. 

A study in the September 2006 issue of the Archives of Surgery reports that wrong-side/wrongsite, wrong-procedure, and wrong-patient adverse events (WSPEs) could be 20 times more common than previously thought and prevention efforts could be inadequate. Physicians Samuel C. Seiden and Paul Barach estimate that it occurs between 1,300 and 2,700 times a year in the United States. The federal National Practitioner Data Bank, a repository of malpractice payments and disciplinary actions, was one of their sources. 


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed the best-known initiative for protecting patients from the WSPE family of surgical blunders. JCAHO sets accreditation standards for 15,000 hospitals and surgical centers nationwide, based on compliance with its suite of National Patient Safety goals. 

One goal in the suite carries the imposing title, Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

This article originally appeared in The Ergonomics Report™ on 2006-11-29.