9 Surgery performed on the wrong site or wrong person has also often been held compensable under malpractice claims. 6, 7 State licensure boards are imposing penalties on surgeons for WSS, 8 and some insurers have decided to no longer pay providers for WSS or wrong-person surgery, nor for leaving a foreign object in a patient’s body after surgery. WSS can be a devastating experience for the patient and have a negative impact on the surgical team. 5Ĭauses and Consequences of Wrong-Site Surgery WSS is also defined as a sentinel event (i.e., an unexpected occurrence involving death or serious physical or psychological injures, or the risk thereof) by the Joint Commission (formerly called the Joint Commission on Accreditation of Healthcare Organizations), which found WSSs to be the third-highest-ranking event. 3 This definition also includes “any invasive procedure that exposes patients to more than minimal risk, including procedures performed in settings other than the OR, such as a special procedures unit, an endoscopy unit, and an interventional radiology suite” 4 (p. 2 Of great concern is wrong-site surgery (WSS), which encompasses surgery performed on the wrong side or site of the body, wrong surgical procedure performed, and surgery performed on the wrong patient. However, until the 1999 Institute of Medicine report, To Err Is Human, 1 clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses because there was no process for recognizing, reporting, and tracking these events. Surgery is one area of health care in which preventable medical errors and near misses can occur.