American Academy of Orthopaedic Surgeons


Wrong Site Surgery

In 1997 the Academy established a task force to examine the subject of wrong site surgery and to develop a protocol for orthopaedic surgeons to prevent even one more incident. The task force

determined that an orthopaedic surgeon has a 1 in 4 chance of performing a wrong site surgery during a 35 year career. Further, in 1997, the Physician’s Insurance Association of America conducted a study covering the insurance payments of 22 different physician insurance companies from across the United States. The study found 225 occurrences of wrong site orthopaedic surgery during an eleven year period, from 1985 through 1995. The survey suggests the impact of wrong site surgery on both patient and physician is significant.

The task force developed a simple protocol for orthopaedic surgeons designed to eliminate wrong site surgery. The protocol was derived from a similar program created by the Canadian Orthopaedic Association and includes three actions

The most common operations in which wrong site orthopaedic surgery may occur are arthroscopic surgery of the lower extremity and spine surgery.

For spine surgery the most common error occurs when the surgeon performs the procedure at one level above the intended site. Wrong site surgery of the spine can be eliminated by using markers that do not move and double checking the level of the spine with an intra-operative x-ray.

However, regardless of the number of precautions, it is possible for surgery to occur at the wrong site. If an error is discovered during surgery while the patient is under general anesthesia, the task force recommends these steps:

If you discover you are operating at the wrong site and the patient is under local anesthesia, proceed to the correct site unless the patient is able to make a competent decision regarding the next step and instructs you to stop.

If you discover the error after surgery has been completed, discuss the situation with the patient and family and recommend a plan to rectify the mistake.

Remember, always be completely truthful and document all discussions, actions, and results in the patient’s medical record. This imperative will help you and the patient in the long run.

Wrong site surgery occurs infrequently, but it can be harmful to both the orthopaedic patient and surgeon. Studies report there is little permanent disability. The most common operative procedures where wrong site surgery occurs are arthroscopic surgery of the lower extremity and spine surgery. Eliminating all wrong site surgery is the Academy’s goal.

Further, the average malpractice insurance payout for wrong site surgery is generally lower than other medical malpractice claims but wrong site surgery almost always results in a payment. By following the Sign Your Site protocol…

you can prevent an incident of wrong site surgery from impacting your patient and your career. Hundreds of orthopaedic surgeons have adopted this surgery protocol to prevent wrong site surgery. They discuss the surgery with the patient before surgery, make a final chart review in the O R, use intraoperative spinal x-rays and markers that don’t move, and place their initials at the operative site with an indelible pen.

Remember….Sign Your Site!


© 1998 American Academy of Orthopaedic Surgeons, Rosemont, IL


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Last modified 11/June/1998 by IS