Wrong-site, wrong-procedure and wrong-patient surgery

The National Quality Forum’s 2025 list of serious reportable events defines it as any surgery or other invasive procedure performed on a body part, site or patient that was not consistent with the correctly documented informed consent for that patient (opens in a new tab), even if it was corrected during the procedure.

The documented consent is the yardstick. The Forum’s examples include the wrong side, the wrong level of the spine, an injection into the wrong knee and removal of the wrong tooth (opens in a new tab), and the definition applies to all healthcare settings that perform such procedures.

“Never event” is a label for events that are unambiguous, serious and usually preventable (opens in a new tab), and the official term is serious reportable event. Neither is a finding of fault.

The Forum excludes known complications of surgery, such as injury to and repair of an adjacent organ during abdominal surgery (opens in a new tab). It counts a complication as known only where the risk was recognized and guarded against, and the complication was found promptly and treated in time.

The Joint Commission’s National Performance Goals for hospitals, in effect since January 1, 2026 (opens in a new tab), require three steps of the hospitals it accredits: a preprocedure verification process, marking of the procedure site, and a time-out before the procedure (opens in a new tab).

A site is marked, at a minimum, when there is more than one possible location for the procedure and operating in a different location would negatively affect quality or safety (opens in a new tab). The time-out comes immediately before starting the invasive procedure or making the incision (opens in a new tab), and in it the team agrees, at a minimum, on the patient’s identity, the site and the procedure to be done.

Federal guidance for surgery centers that take Medicare says generally accepted procedures require the same three steps (opens in a new tab). The American College of Surgeons recommends that, where a site could be on either side, the operating surgeon mark it before the patient is given narcotics, sedatives or anesthesia (opens in a new tab).

Illinois’s rule on hospital surgical policies speaks of surgical privileges, maintenance of the operating rooms, and evaluation of the surgical patient (opens in a new tab). It does not mention a time-out or site marking.

These are the documents of an accrediting body, a federal agency and a professional society, and the College says its statement does not constitute a standard of care (opens in a new tab). What careful practice required in a particular operating room is for a qualified expert in the same field to explain.

Rarely, and the estimates are rough. A 2015 review of studies put wrong-site surgery at 1 event per 100,000 procedures and said the precision is uncertain (opens in a new tab).

An earlier study of cases reported to one large malpractice insurer between 1985 and 2004 found 25 wrong-site operations among 2,826,367 operations, or 1 in 112,994, with spine surgery left out (opens in a new tab).

A primer on the Agency for Healthcare Research and Quality’s Patient Safety Network notes that the insurer estimate only included procedures performed in the operating room (opens in a new tab), and that formal reviews of these errors consistently reveal communication issues as a prominent underlying factor.

A caution applies to both figures. The second counts cases reported to one malpractice insurer, which is not every patient, and the review calls its own estimate uncertain. Neither says anything about any one operation.

No label decides a lawsuit. In some cases Illinois lets negligence be inferred from the circumstances (opens in a new tab), under a doctrine called res ipsa loquitur. The Illinois Supreme Court says the patient must prove an injury in an occurrence that ordinarily does not happen in the absence of negligence, by something within the defendant’s exclusive control (opens in a new tab), and a judge decides first whether the doctrine applies.

The doctrine gets a case to a jury and does not decide it. The court says the trier of fact is free to accept or reject the inference (opens in a new tab), and that the duty of care and the cause of the injury must be proven apart from it.

Expert testimony is ordinarily still needed. The court required it where an injury was of a type outside the common knowledge of laymen (opens in a new tab).

The deadlines and the other rules for an Illinois malpractice claim are on our page about Illinois malpractice law.

Start with two documents. Illinois hospital rules require a properly executed consent for the proposed procedure to be in the chart before surgery (opens in a new tab), and an operative report describing techniques and findings, written or dictated immediately following surgery (opens in a new tab).

The time-out leaves less. The Joint Commission requires an accredited hospital to document the completion of the time-out, and lets the hospital determine the amount and type of documentation (opens in a new tab).

You can ask the hospital for your own records, and our Illinois law page explains how. If you were told that the wrong site, procedure or patient was involved, write down the date, who told you and what was said.