Wrong site surgery

*Changes to the core list for 2010/11 are marked in bold

Description

A surgical intervention performed on the wrong site (for example wrong knee, wrong eye, wrong patient, wrong limb, or wrong organ); the incident is detected at any time after the start of the operation and the patient requires further surgery, on the correct site, and/or may have complications following the wrong surgery.

Main care setting

Organisations that provide major, minor and/or day case surgery. Dentistry continues to be excluded.

Preventative guidance

The Chief Medical Officer for England identified that errors involving operations on the wrong side or part of the body are 'particularly worrying for the public, especially when they are repeated'. Operating on the wrong site can have devastating consequences for patients. Implementation of the following guidance can help providers to prevent wrong site surgery:

• Patient safety notice: standardising wristbands improves patient safety

  NPSA guidance on the use of wristbands for patient identification

• Patient safety alert - WHO Surgical Safety Checklist

  The NPSA, in collaboration with a multi-professional expert reference group, adapted the WHO Surgical Safety Checklist for use in England and Wales. This alert includes advice to the NHS on implementing the checklist and incorporates previous best practice identified by the NPSA and the Royal College of Surgeons on making surgery safer in its Patient safety alert - Correct site surgery from 2005.