Wrong Client, Site, and / or Procedure

Wrong client, site, and procedure encompasses procedures performed on the wrong client, wrong body part, wrong side, wrong level (e.g., spine), and incorrect procedures. As these incidents are generally considered to be preventable, they can be difficult to defend (Canadian Medical Protective Association & HIROC, 2016). In 2015, surgery on the wrong body part or the wrong client, or conducting the wrong procedure was recognized as one of Canada’s “never events” (defined as “patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances” (Canadian Patient Safety Institute & Health Quality Ontario, 2015)). Failure to verify the client's identity, incorrect site or procedure on the consent form, miscommunication between team members, and workload are contributing factors in these incidents. Verification protocols, safety checklists, and creating a culture of safety are key to managing this risk.

Expected Outcomes

Adopt standardized best practice processes for:
o        Scheduling inpatient and ambulatory surgeries and procedures to optimize the preoperative verification process;
o        Surgical site marking and verification process.

Implement formal strategies to support and enhance safety culture in the perioperative care settings.

Adopt current best practice quality indicators for perioperative care.

Definitions and Acronyms

  • Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
  • OR – operating room
  • Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning.

Common Claim Themes and Contributing Factors

Frequently involve
  • Knee and hip surgery.
  • Spinal surgery.
  • Perceived or actual systematic tolerance of unprofessional and unsafe behaviours as well as steep hierarchical culture in the perioperative care settings.
Knowledge and Judgement
  • Non-compliance with surgical safety checklist process due to practice drift, normalization of deviance, and perceived and actual time pressure.
  • Surgical timeout and / or pre-surgery huddles inconsistently performed and variations in practices between teams.
  • Orthopedic surgeries:
    • Inadequate surgical site marking and / or not visible after prepping and draping;
    • Correct site marked however tourniquet applied to the wrong leg and / or drape covered the marked surgical site;
    • Surgical site marking is not indicative of the surgery to be performed (e.g., surgical site marking on hip for knee arthroscopy).
  • Spinal surgeries:
    • Failure to obtain and / or repeat intraoperative x-rays or fluoroscopic images where indicated;
    • Inadequate / poor quality intraoperative images; 
    • Inadequate and variations in spinal level counting practices;
    • Failure to consider the possibility of spinal anatomical variations.
  • Inadequate and ineffective (passive, "hint and hope", etc.) surgical team and client communication.
  • Hesitancy to escalate concerns about unsafe practices and practitioners, including practitioners in leadership roles, often related to the hierarchical culture in the OR.
  • Lack of team situational awareness during preoperative briefings, timeout, and debriefings.
  • Inaccurate and / or incomplete consent forms, pre-operative checklists.

Mitigation Strategies

Preoperative Processes

  • Adopt best practices for scheduling inpatient and ambulatory surgeries to support the presence of and accurate documentation to assist with pre-procedure verification processes, that include (but is not limited to):
    • Discouraging the practice of verbal bookings;
    • A formal change management process (e.g., checklist) to ensure all related documents are amended whenever a documentation error or discrepancy is identified.

Surgical Site Marking and Verification Processes

  • Adopt best practice for surgical site marking (e.g., use of indelible markers, the mark is made as close to the surgical site as possible, and is visible in the prepped and draped field and during the timeout and intraoperative verification).
  • Adopt a standardized best practice for the marking and verification of the surgical site for spinal surgeries (preoperative and intraoperative x-ray using stable maker in order to verify spine level, a spine-specific surgical safety checklist, standardized counting procedures for spines, etc.) (DeVine, Chutkan, Gloystein, & Jackson, 2020) (Kulkarni, Patel, Asati, & Mewara, 2022) (Epstein, 2021).
  • Adopt a standardized best practice surgical safety checklist to support effective teamwork and client safety during the perioperative care (Canadian Patient Safety Institute, n.d.).
  • Where multiple procedures are being performed, including anesthetic nerve blocks, implement a standardized process to support the performance of a separate site marking process and timeout with all staff involved in the procedure (Martin, 2018) (Harris, Ortolan, Edmonds, Fields, & Liguori, 2021) (O'Neill, Cherreau, & Bouaziz, 2010).
  • Adopt a standardized formal process for resolving verification discrepancies during the preoperative, intraoperative, and postoperative phases of care.


  • Adopt a standardized and structured communication framework for team (intra- and inter-disciplinary) communication during the preoperative, intraoperative and postoperative phases of care (e.g., SBAR, closed loop communication) (Etherington, Wu, Cheng-Boivin, Larrigan, & Boet, 2019).

Safety Culture

  • Implement formal strategies to develop and maintain a work environment which supports and expects:
    • Interprofessional collaboration and collegiality;
    • Zero tolerance of intra- and inter-disciplinary bullying and intimidation;
    • Assertive and respectful questioning and challenging of unsafe practices (BC Patient Safety & Quality Council, 2021) (Sacks, et al., 2015) (Bello, et al., 2022) (Etherington, Wu, Cheng-Boivin, Larrigan, & Boet, 2019).
  • Adopt a standardized, formalized, and program-specific chain of command (escalation) protocol for the rapid escalation of unresolved care concerns or disagreements related to orders, decisions, and / or unsafe practices.


  • Implement formal strategies to improve documentation of the surgical safety verification process (e.g., was the briefing, time out and debriefing documented in the intraoperative records).

Team Training and Education

  • Implement formal strategies to support and enhance the team’s clinical knowledge, skills (technical and non-technical), and practical experience regarding prevention of wrong client, site and / or procedure as well as the surgery safety checklist, including (but not limited to) scheduled interprofessional and cross-department skill drills and simulations.
  • Ensure the scheduled interprofessional and cross department team training and education strategies address or involve: 
    • Team and practitioner situational awareness (‘helicopter view’) and human factors;
    • Communication training; 
    • Unregulated care providers (where utilized), locums, travel, agency, contracted care providers, in addition to regulated health professionals.

Monitoring and Measurement

  • Adopt current best practice quality indicators for perioperative care (Gilhooly, Chazapis, & Moonesinghe, 2020) including (but not limited to) indicators for:
    • Never events and use of the surgical safety checklist;
    • Spinal surgeries;
    • Orthopedic surgeries;
    • Colonoscopy, endoscopy, and gastroscopy procedures.
  • Adopt a standardized, interdisciplinary, collaborative and evidence-based protocol for conducting quality of care reviews involving wrong client, site and / or procedure resulting in client harm or death; incorporate system thinking and human factors concepts into the review process (Machen, 2023).
  • Incorporate learning from local, provincial, and national reviews and data regarding wrong client, site and / or procedure into local protocols as well as staff education and training (Canadian Medical Protective Association & HIROC, 2016) (Yonash & Taylor, 2020).

  • BC Patient Safety & Quality Council. (2021). A rapid review of the literature: Measuring culture to inform action. Retrieved from http://ow.ly/Qaq450EeMW0
  • Bello, C., Filipovic, M., Andereggen, L., Heidegger, T., Urman, R., & Luedi, M. (2022, 8). Building a well-balanced culture in the perioperative setting. 
  • Canadian Medical Protective Association & HIROC. (2016). Surgical safety in Canada: A 10-year review of CMPA and HIROC medico-legal data. 
  • Canadian Patient Safety Institute. (n.d.). Surgical safety checklist: Download . Retrieved from https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/SurgicalSafety-Checklist-Resources.aspx#
  • DeVine, J., Chutkan, N., Gloystein, D., & Jackson, K. (2020, 1). An Update on Wrong-Site Spine Surgery. 
  • Epstein, N. (2021, 6). A perspective on wrong level, wrong side, and wrong site spine surgery. 
  • Etherington, C., Wu, M., Cheng-Boivin, O., Larrigan, S., & Boet, S. (2019, 10). Interprofessional communication in the operating room: a narrative review to advance research and practice. 
  • Gilhooly, D., Chazapis, M., & Moonesinghe, S. (2020, 12). Prioritisation of quality indicators for elective perioperative care: a Delphi consensus. 
  • Harris, S., Ortolan, S., Edmonds, C., Fields, K., & Liguori, G. (2021, 7). Fewer Wrong-Site Peripheral Nerve Blocks Following Updates to Anesthesia Time-Out Policy. 
  • Kulkarni, A., Patel, J., Asati, S., & Mewara, N. (2022, 2). “Spine Surgery Checklist”: A Step towards Perfection through Protocols. 
  • Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
  • Martin, D. (2018). Anesthesia alert: Tips to avoid wrong-site nerve blocks. Retrieved from Outpatient Surgery: https://www.aorn.org/outpatient-surgery/article/2018-November-anesthesia-alert-tips-to-avoid-wrong-site-nerve-blocks
  • O'Neill, T., Cherreau, P., & Bouaziz, H. (2010, 2). Patient safety in regional anesthesia: preventing wrong-site peripheral nerve block. 
  • Sacks, G., Shannon, E., Dawes, A., Rollo, J., Nguyen, D., Russell, M., . . . Maggard-Gibbons, M. (2015, 7). Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture. 
  • Yonash, R., & Taylor, M. (2020, 12). Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities.