When the surgeon chooses the wrong organ: A more frequent error than previously thought

It may seem like a joke to see someone go into an operating room to have their right kidney removed and come out without their left one, but it is far from it. Mistakes like this happen, and their consequences are often tragic, even lethal. Operating on the wrong side, on a different organ, on the wrong patient, or with the wrong procedure are all cases of what is known as wrong-site surgery (WSS). And although they are rare, they are more common than one might think. The implementation of verification protocols and new technologies attempt to ensure that these “never events,” as the medical jargon refers to events that should never occur, do not actually happen.

In September 2024, a patient in the United States died when the surgeon operating on his spleen removed his liver instead. This is the latest in a series of particularly severe cases, especially in the United States, but there is a reason for this: “WSS has not been under the same scrutiny in other parts of the world,” wrote a team led by orthopedic surgeon Christos Tsagkaris, of the European Student Think Tank’s public health and policy working group, in the journal Baylor University Medical Center Proceedings. In Europe, there are only seven studies from 2006 to 2022, but this scourge, which Tsagkaris says is “the fourth most significant preventable problem in the healthcare field,” occurs even in “high-income countries with state-of-the-art healthcare systems.”

In the U.S., there is an abundance of data: an incidence of between 0.09 and 4.5 per 10,000 operations, with a total of 2,447 cases in 20 years. The National Health Service in the United Kingdom publishes annual figures, with a count of 179 cases of WSS in one year, from April 2023 to March 2024. A small study with data from Spain presented at a conference in 2019 recorded only 81 cases in 11 years, which contrasts with previous figures. According to the director of that research, anesthesiologist Daniel Arnal, from the Hospital Universitario Fundación Alcorcón in Madrid, “there is no reliable record at national or international level (and I stress the word international) that records this type of adverse event.”

Arnal underlines that figures from other countries are only estimates, something that is corroborated by Adam Taylor, a professor of anatomy and director of the Clinical Anatomy Learning Centre at Lancaster University (United Kingdom), who says he is not aware of centralized databases in Europe: “Each country has its own registration system, some voluntary, others mandatory,” he notes. Tsagkaris mentions the European Union Joint Action on Patient Safety and Quality of Care (PaSQ), which “has promoted the creation of national registers to report on patient safety incidents.”

Only one in 10 cases is recorded

“In Spain, incident reporting systems are also fragmented among the different autonomous regions,” which use different procedures, adds Arnal. Despite this, says the anesthesiologist, “the level of reporting in Spain is better than in most of Europe, although with great variability depending on the area and hospital.” In general, he says, only 10% of incidents are reported.

Trauma surgeon Diego García-Germán, author of several articles on WSS, agrees with this underestimation of real cases. “There is no such registry in Spain,” he says. His interest in this problem arose from the fact that his specialty is the one most affected by these errors. Of all WSS cases, the majority occur in orthopedic surgery operations — especially in the knee — due to the bilateral nature of the extremities in which there are often no external signs of the condition. A recent study, once again conducted in the U.S., attributes 35% of these errors to this specialty, with 22% in neurosurgery and 9% in urology. Other data have raised the figure in orthopedic surgery to 41% or even 68% of the total.

As for the causes, according to Taylor, “it is usually a combination of factors.” Tsagkaris and his colleagues explain that these incidents are based on the Swiss cheese model defined by psychologist James Reason and used to explain, for example, plane crashes, which are usually the result of an accumulation of errors — the holes in the cheese — in several scenarios, represented by slices of cheese placed in parallel: when there are holes aligned in each slice, allowing a straight line to pass through them, the accident occurs. In WSS, failures in systems or processes can come together, from the organization — the workload and pressure –— planning — for example, placing the X-ray upside down on the screen — preoperatively — such as not marking the site to be operated on on the skin — and within the operating room itself, which includes distractions or lack of information.

Solutions

Arnal insists that it is important “not to generate unnecessary alarm.” There are many initiatives aimed at improving patient safety, an objective that is the focus of the activity of the scientific society Sensar, founded by the anesthesiologist, who cites a long list of repeated checks that are common in Spain. The World Health Organization created a Surgical Safety Checklist, which is widely used. However, according to García-Germán, “each hospital uses its own procedure.” For the traumatologist, there is no need for a single universal standard either: he stresses above all the importance of “the process, coordination, organization, teamwork, and communication with the patient. You have to talk to them and confirm the site and the procedure.”

In addition to protocols, technological tools are emerging that aim to assist surgical staff in preventing WSS. One example is the StartBox Patient Safety System, which consists of a cell phone app, a recording tool, and an instrument kit. More radical is Surgical Safety Systems’ Black Box system; as its name suggests, it is inspired by the black boxes on airplanes, collecting video in the operating room itself. Although the system anonymizes images of medical staff, the installation of this tool has been sabotaged in some U.S. hospitals.

The experts consulted appreciate the contribution of new technologies, but with reservations. “As far as I know, none of these technologies have been recommended or supported by verifiable scientific results,” says Arnal. For García-Germán, “it is not necessary to make it so cumbersome.” Tsagkaris stresses the importance of privacy for professionals and patients: “There are legal and cultural aspects that must be respected and addressed,” he concludes.

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