A comprehensive discussion of “never events” or preventable and grievously shocking medical errors that may result in serious morbidity and mortality is incomplete without a thorough analysis of wrong‐site procedures (WSP). These occurrences are often due to multiple, simultaneous failures in team processes and communication. Despite being relatively rare, wrong‐site surgery can be devastating to all parties involved, from patients and families to healthcare workers and hospitals. This chapter provides a general overview of the topic in the context of clinical vignettes discussing specific examples of WSP. The goal of this work is to educate the reader about risk factors and preventive strategies pertinent to WSP, with the hope of propagating the knowledge required to eliminate these “never events.” To that end, the chapter discusses pitfalls in current surgical practice that may contribute to critical safety breakdowns and emphasizes the need for multiple overlapping measures designed to improve patient safety. Furthermore, updated definitions regarding WSP are included in order to better characterize the different types of WSP. Most importantly, this chapter presents evidence‐based support for the current strategies to prevent wrong‐site events. A summary of selected recent wrong‐site occurrences is also provided as a reference for researchers in this important area of patient safety.
Part of the book: Vignettes in Patient Safety