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Wrong site surgery
  1. S G Fraser,
  2. W Adams
  1. Sunderland Eye Infirmary, Queen Alexandra Road, Sunderland SR2 9HP, UK
  1. Correspondence to: MrScott Fraser Sunderland Eye Infirmary, Queen Alexandra Road, Sunderland SR2 9HP, UK; sfraser100{at}

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A great deal of work needs to be done to reduce and potentially eliminate this most basic of errors

Wrong site surgery (WSS) is likely to be as old as surgery itself. Within ophthalmology Traquair, in 1947, described the “important and very pertinent disaster of wrong site surgery where enucleations of the wrong eye have been performed.”1 Although among the pantheon of medical errors it is relatively rare, the consequences can be disastrous—for example, removing the wrong eye when its fellow is blind. Because of the potentially serious nature of this error, a number of organisations have focused their efforts in reducing the occurrence. Unusually, in the field of medical error, WSS errors are thought to be entirely preventable. This has led to the adoption of a number of broadly similar protocols and guidelines to try to remove this most devastating of mistakes.


Wrong site surgery can be simply defined as “the performance of an operation or surgical procedure on the wrong part of the body.”2 Within this particular definition there are a number of subcategories:

  • Incorrect side (for example, left eye rather than right), which can obviously only occur with paired structures such as kidneys, ovaries, or eyes

  • Correct side but incorrect location—occurs where there is more than one similar anatomical structure to choose from (for example, incorrect finger on the correct hand or incorrect eye muscle on correct eye)

  • Correct side and correct anatomical site but the incorrect operation (for example, resection of a muscle rather than recession).

The American, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes the above but also extends the definition to include2:

  • Wrong patient surgery

  • Wrong procedures.

Ophthalmology is one branch of surgery that is liable to any of the wrong site errors described above. The stakes are …

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