Wrong-site surgery happens when a medical procedure is performed on the wrong part of a patient’s body. It may involve the wrong side, the wrong body part, or the wrong anatomical level, such as the incorrect level of the spine. A closely related group of surgical errors includes performing the wrong procedure or operating on the wrong patient altogether.

These are not ordinary surgical complications. According to Patient Safety Network, wrong-site, wrong-procedure, and wrong-patient procedures are considered “never events” because they should not occur and can indicate serious underlying patient-safety problems. The consequences can include an unnecessary operation, delayed treatment of the actual medical condition, corrective surgery, permanent injury, or death.

If you or a family member underwent surgery at the wrong location or experienced another serious preventable surgical error, Shebell & Shebell’s medical malpractice attorneys in New Jersey can help you understand whether the circumstances may support a claim. This guide explains the different forms of wrong-site surgery, how often these errors occur, why they happen, how hospitals are supposed to prevent them, the injuries they can cause, and when a surgical error may amount to medical malpractice.

What is Wrong-Site Surgery?

Wrong-site surgery occurs when a surgeon or other healthcare professional performs an invasive procedure at an anatomical location different from the one intended for that patient.

The mistake may be obvious, such as operating on the left leg instead of the right, but some wrong-site errors are more difficult to recognize immediately.

Wrong-Side Surgery

Wrong-side surgery occurs when the correct procedure is performed on the wrong side of the body.

Examples could include operating on the:

• Left knee instead of the right knee
• Wrong eye
• Wrong arm or leg
• Wrong kidney or other paired organ

The patient may then face two separate medical problems: harm caused by the unnecessary operation and continued need for treatment on the correct side.

Wrong Body Part or Organ

A surgeon may also operate on or remove the wrong body part, organ, lesion, or area of tissue.

Depending on the procedure, the consequences can range from an unnecessary incision to irreversible loss of healthy tissue or an organ.

Wrong-Level Surgery

Wrong-level surgery is particularly important in spinal procedures.

A surgeon may correctly identify that a patient requires surgery on the lumbar or cervical spine but operate at the wrong vertebral level. The procedure is therefore performed in the correct general area of the body but at the wrong anatomical location.

Operating on the wrong spinal level is a recognized example of wrong-site surgery and has been a particular concern in neurosurgical and spinal procedures.

Wrong-Procedure or Wrong-Patient Surgery

Wrong-procedure and wrong-patient surgery are separate but closely related safety failures.

Wrong-procedure surgery occurs when a healthcare team performs a procedure different from the one that was actually planned. Wrong-patient surgery occurs when a procedure intended for one patient is performed on another.

Together, wrong-site, wrong-procedure, and wrong-patient events are often discussed as one category because many of the same failures—patient identification problems, incorrect records, scheduling mistakes, and communication breakdowns—can lead to each type of error.

How Often Does Wrong-Site Surgery Happen?

Wrong-site surgery is considered rare, but it has not been eliminated despite decades of safety initiatives.

Because reporting systems differ and some studies only capture procedures performed in traditional operating rooms, there is no single number that describes every wrong-site event in the United States.

Wrong-Site Surgery is Rare but Still Occurs

A major study estimated that wrong-site, wrong-procedure, and wrong-patient errors occur in approximately 1 out of every 112,000 surgical procedures. That estimate included operating-room procedures and did not capture every invasive procedure performed in ambulatory settings, interventional radiology, or other locations.

AHRQ also notes research showing that these errors can occur outside traditional operating rooms, meaning operating-room statistics alone may underestimate the broader problem.

What Medical Malpractice Claims Show

A review of closed malpractice claims provides additional insight into where wrong-site errors occur.

According to the American College of Surgeons, researchers examined 68 closed wrong-site surgery claims from 2013 through 2020. Orthopaedic services were involved in 35.3% of the claims, neurosurgery in 22.1%, and urology in 8.8%. Spine and intervertebral-disc procedures accounted for 22.1% of the procedures studied, while arthroscopy accounted for 14.7%.

Errors can also begin well before an incision is made. According to a 2024 Patient Safety Journal study, researchers reviewed 1,166 reports involving consent or scheduling errors at Pennsylvania hospitals and ambulatory surgical facilities. Wrong-side errors represented 69% of the error subtypes identified. These were consent and scheduling errors that can increase the risk of wrong-site surgery—not 1,166 completed wrong-site operations.

Why Does Wrong-Site Surgery Happen?

Wrong-site surgery usually cannot be reduced to a single mistake made in one moment. Information passes through physicians’ offices, schedulers, nurses, surgical teams, consent forms, medical records, and operating-room staff before a procedure begins.

A breakdown anywhere along that chain can create risk.

Failure to Follow Safety Protocols

Hospitals and surgical centers generally have procedures intended to verify the patient, planned operation, and surgical location before the procedure begins.

The problem is sometimes not that a safety policy does not exist. It is that the policy is skipped, rushed, misunderstood, or inconsistently followed.

Failure to follow established policy or protocol was the leading contributing factor in the 68 wrong-site surgery claims reviewed by researchers. Failure to properly review medical records was another major contributing factor.

Communication Breakdowns

Surgery involves multiple people, and each person may be working from information provided at a different stage of the patient’s care.

Problems can arise when a physician’s office identifies one side but the surgical schedule identifies another, when a planned procedure changes but the update is not communicated, or when members of the operating team notice conflicting information but do not stop the process.

Communication problems consistently appear in analyses of wrong-site, wrong-procedure, and wrong-patient errors. Preventing them depends not only on written procedures but also on teamwork and a culture where staff are expected to identify and resolve inconsistencies.

Incorrect Records, Consent Forms, or Scheduling

A wrong-site error may begin before the patient ever reaches the hospital.

Possible problems include the wrong side being entered on the schedule, an incorrect procedure appearing on a consent form, inaccurate charting, conflicting medical records, or staff failing to compare those documents before surgery.

This is why inconsistencies between the physician’s order, surgical schedule, patient consent, imaging, and medical records should be resolved rather than assumed to be harmless paperwork errors.

The 2024 Patient Safety Journal study found that scheduling errors were more common than consent errors in its sample and that wrong-side errors were the most frequently reported subtype.

Site-Marking and Time-Out Failures

Marking the surgical site is intended to provide a clear visual confirmation of where the procedure will occur. Problems may develop if the site is not marked, the wrong site is marked, the mark is ambiguous, or it is no longer visible after the patient is positioned and prepared for surgery.

The surgical “time-out” provides another safeguard. Immediately before beginning the procedure, the surgical team pauses to verify important information such as the patient, procedure, and operative site.

But simply having a time-out policy does not guarantee that it works.

Time-outs can be rushed or ineffective, and errors may originate long before the patient enters the operating room. Production pressure and failure to resolve conflicting information can undermine otherwise appropriate safety procedures.

How Wrong-Site Surgery is Supposed to Be Prevented

Wrong-site surgery has received significant attention from healthcare safety organizations precisely because there are practical steps that can reduce the risk.

The Joint Commission Universal Protocol

The Joint Commission developed the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery to create a standardized verification process.

The protocol centers on three major safeguards: preprocedure verification, marking the procedure site, and performing a final time-out before the procedure begins.

Together, those safeguards are intended to confirm the correct patient, planned procedure, surgical site, side or anatomical level when applicable, relevant medical records and imaging, and consistency between the planned operation and the patient’s consent.

Preprocedure verification is supposed to identify discrepancies before the patient reaches the point of surgery. Site marking creates a visible confirmation of the intended location. The final time-out gives the entire team one last opportunity to stop if something does not match.

These protections are important, but they are not foolproof.

Some wrong-site events can still occur despite established protocols because the original error began earlier, the time-out was ineffective, or the team failed to recognize and act on conflicting information. Preventing these events ultimately requires both formal safety systems and healthcare professionals who consistently use them.

What Harm Can Wrong-Site Surgery Cause?

The harm from wrong-site surgery is not limited to the unnecessary procedure itself.

A patient may suffer tissue or nerve damage at the incorrect surgical site while the medical problem that originally required surgery remains untreated. That can mean another operation, another exposure to anesthesia, additional recovery time, and a delay in treating the original condition.

Possible consequences include unnecessary tissue damage, nerve injuries, infection, scarring or disfigurement, reduced mobility, chronic pain, additional surgery, delayed treatment, loss of healthy tissue or an organ, permanent functional limitations, emotional trauma, disability, and in the most serious cases, death.

The available malpractice data reflects how significant these consequences can be. 45.6% of the 68 wrong-site surgery claims studied involved the need for additional surgery. Pain was alleged in 33.8%, while other reported injuries included mobility dysfunction, worsened injuries, scarring, total loss, and death.

The consequences may be particularly serious when the original operation was time-sensitive. A patient who receives surgery on the wrong location may still need the correct procedure afterward, while the underlying disease or injury has had additional time to progress.

When is Wrong-Site Surgery Medical Malpractice?

Wrong-site surgery can be strong evidence of medical negligence, but a malpractice claim still requires proof that a healthcare provider departed from accepted standards of care and that the departure caused actual harm.

That distinction matters because not every poor surgical outcome is malpractice. Surgery carries recognized risks even when the medical team provides appropriate care. A preventable error involving the wrong patient, procedure, side, or site presents a very different issue.

Wrong-site surgery is one type of preventable surgical error. For a broader look at how surgical mistakes happen, what may qualify as malpractice, and what legal options patients may have, read our surgical errors guide.

Standard of Care and Breach

Medical providers are expected to use the level of professional care appropriate to the circumstances.

In a wrong-site case, the standard of care may involve basic safeguards such as confirming the patient’s identity, reviewing the operative plan, checking consent documents and imaging, identifying the correct surgical site, and participating meaningfully in the final time-out.

If a surgeon or other provider fails to follow reasonable verification procedures and operates on the wrong location, that failure may represent a breach of the applicable standard of care.

The same can be true when the error results from another member of the healthcare team or from a broader hospital system failure. Determining where the process broke down is often an important part of evaluating the malpractice claim.

Causation and Harm

A preventable error must also be connected to the patient’s injuries and losses.

Depending on what happened, that harm may include an unnecessary surgical procedure, the need for corrective surgery, a delay in receiving the treatment originally required, permanent physical injury, additional medical expenses, extended recovery, time away from work, or lasting functional limitations.

The key point is that a bad surgical result alone does not prove malpractice. The issue is whether a healthcare provider departed from accepted care and whether that departure caused additional harm to the patient. That is the same basic distinction made in broader surgical-error malpractice cases.

Who Can Be Held Responsible?

Wrong-site surgery is rarely just a question of what the surgeon did in the operating room. The error may begin with scheduling, documentation, patient identification, or communication before the procedure ever starts.

Who may be legally responsible depends on where the breakdown occurred and the relationship between the healthcare providers and facility involved.

Surgeon

The surgeon may be responsible when the error involves failures such as:

• Not verifying the correct surgical site
• Ignoring conflicting records or imaging
• Operating on the wrong side or anatomical level
• Failing to properly participate in the surgical time-out
• Proceeding despite uncertainty about the intended procedure

Because the surgeon ultimately performs the operation, their actions are often a major focus of a wrong-site surgery investigation.

Nurses, Technicians, and Other Staff

Operating-room nurses, surgical technicians, and other healthcare professionals may also play a role in identifying the patient, preparing the surgical site, reviewing documentation, and participating in the time-out.

Potential problems can include incorrect preparation, documentation errors, communication failures, or failing to raise concerns when information does not match.

Hospital or Surgical Facility

Some wrong-site surgeries point to a broader systems problem rather than one individual mistake.

Issues may involve:

• Scheduling procedures incorrectly
• Poor medical record systems
• Patient-identification failures
• Inadequate staffing
• Failure to implement or enforce safety protocols
• Communication breakdowns between departments

Whether a hospital or surgical center can be held responsible depends on the specific facts, including who employed the providers involved and how the error occurred.

Proving a Wrong-Site Surgery Claim in New Jersey

Even when the error appears obvious, a medical malpractice case still requires evidence showing what happened, who was responsible, and how the mistake harmed the patient.

Important Evidence

Records from before, during, and after the procedure can help reconstruct how the error occurred.

Important evidence may include:

• Operative reports
• Surgical consent forms
• Scheduling records
• Preoperative records
• Imaging studies
• Surgical-site marking documentation
• Nursing notes
• Anesthesia records
• Corrective surgery records
• Photographs
• Follow-up treatment records

Comparing these records can be particularly important. For example, the consent form may identify the right knee while the surgical schedule incorrectly identifies the left.

Medical Expert Review

New Jersey medical malpractice claims generally require qualified medical professionals to evaluate whether the care fell outside accepted professional standards.

New Jersey also has an Affidavit of Merit requirement. According to New Jersey law, a plaintiff in a qualifying medical malpractice action generally must provide each defendant with an affidavit from an appropriate licensed professional within 60 days after that defendant files an answer. A court may allow one additional period of up to 60 days for good cause.

The affidavit essentially confirms that there is a reasonable probability that the care provided fell outside acceptable professional standards. The exact expert requirements can depend on the specialty and circumstances involved.

Compensation That May Be Available

The damages in a wrong-site surgery case depend on the harm the patient actually suffered.

Compensation may potentially address:

• Corrective surgery and additional treatment
• Future medical care
• Lost wages
• Reduced future earning capacity
• Pain and suffering
• Emotional distress
• Permanent disability
• Scarring or disfigurement
• Loss of enjoyment of life

A patient who required a second procedure but ultimately recovered may have very different damages from someone who suffered irreversible nerve damage, loss of an organ, permanent mobility problems, or another life-altering injury.

If wrong-site surgery results in death, surviving family members may also have claims arising from the patient’s death.

Filing Deadlines

Wrong-site surgery claims also have filing deadlines.

Medical malpractice actions involving personal injury are generally governed by a two-year statute of limitations. New Jersey also recognizes a discovery rule in certain cases, meaning the limitations period may not begin until the injured person discovers, or reasonably should have discovered, that there may be a basis for a claim.

Because determining when a claim legally “accrued” can depend on the facts, patients should not assume that they have two years from the day they personally realized something went wrong.

What Should You Do After Discovering a Wrong-Site Surgery?

The immediate priority should be addressing the medical consequences. After that, preserving information about what happened can become important.

Get Appropriate Medical Care

A patient may need evaluation from another surgeon or specialist, particularly if the incorrect procedure caused an injury or the original condition still requires treatment.

Some patients may also require corrective surgery, rehabilitation, pain management, or other follow-up care.

Request Your Medical Records

Request and preserve records relating to the procedure, including:

• Operative reports
• Consent documents
• Imaging
• Preoperative records
• Discharge instructions
• Follow-up records

These records may help show what procedure was supposed to occur and what actually happened.

Document the Impact

Keep track of how the error has affected your health and daily life.

That can include symptoms, additional procedures, missed work, medical expenses, photographs of surgical sites or scarring, and significant conversations with healthcare providers.

Do Not Assume a Consent Form Ends the Issue

Signing a surgical consent form does not mean a patient agreed to every mistake that could happen during an operation.

There is an important difference between accepting recognized risks of the intended procedure and undergoing surgery on the wrong side, body part, organ, spinal level, or other anatomical location.

Whether malpractice occurred still depends on the circumstances, but a signed consent form does not automatically excuse negligent medical care.

Frequently Asked Questions About Wrong-Site Surgery

Is Wrong-Site Surgery a Never Event?

Yes. Wrong-site, wrong-procedure, and wrong-patient surgeries are commonly classified as “never events” because they are serious patient-safety incidents that should be prevented through established verification procedures.

Is Wrong-Site Surgery Always Medical Malpractice?

Not automatically in the legal sense. A malpractice claim still requires proof of a departure from accepted medical care, causation, and resulting harm. However, operating on the wrong anatomical site can provide significant evidence that something went seriously wrong in the care process.

What is the Difference Between Wrong-Site and Wrong-Side Surgery?

Wrong-side surgery is one specific form of wrong-site surgery. For example, operating on the left knee instead of the right knee is a wrong-side error. Wrong-site surgery can also involve the wrong organ, body part, lesion, or anatomical level.

Can Wrong-Level Spine Surgery Be Malpractice?

Potentially. If surgery is performed at the wrong vertebral level because appropriate verification procedures were not followed, the error may support a medical malpractice claim when it causes harm.

Who Can Be Liable for Wrong-Site Surgery?

Potentially responsible parties can include the surgeon, nurses, surgical technicians, other healthcare providers, and the hospital or surgical facility. Liability depends on how the error occurred and the professional or employment relationships involved.

Can I File a Claim if I Signed a Consent Form?

Potentially, yes. Consent to an intended surgery does not necessarily constitute consent to having an entirely different body part, side, organ, or anatomical level operated on.

Speak With a New Jersey Medical Malpractice Attorney

Wrong-site surgery can create two separate injuries: the harm caused by an unnecessary procedure and the consequences of delaying the treatment the patient actually needed. Surgical-site verification, accurate records, site marking, communication, and the final time-out exist specifically to prevent these mistakes.

If you or a loved one underwent surgery on the wrong side, body part, organ, or anatomical level, Shebell & Shebell’s medical malpractice attorneys in New Jersey can review what happened and explain whether the circumstances may support a medical malpractice claim.