From the Operating Room to the Courtroom: Wrong-Site Surgery

Abstract

Introduction: Wrong-site surgery (WSS) is considered a “never event” and represents a serious and fully preventable patient safety issue. Despite international protocols, these incidents continue to occur, leading to significant clinical, legal, and social consequences. This study aimed to analyze wrong-site surgery cases reported in Supreme Court decisions and the media in Türkiye, identifying their characteristics and legal implications from a forensic medicine perspective. Material Methods: A retrospective review was conducted using the legal database lexpera.com.tr and Google News search engine. Keywords such as “wrong-side surgery” and equivalent Turkish terms were used to identify cases between 2010 and 2025. A total of 22 cases meeting inclusion criteria were analyzed. Descriptive statistics were performed using SPSS v21.0. Results: Among the 22 cases, 45.5% involved orthopedic surgery, followed by ophthalmology and general surgery (each 13.6%). The most common surgical sites were lower (31.8%) and upper extremities (22.7%). Wrong-site surgery was most frequently reported in public hospitals (45.5%), followed by university/research hospitals (31.8%). Legal analysis revealed that several decisions initially favoring physicians at local courts were overturned in Supreme Courts, mostly in favor of patients, indicating significant medico-legal risk. Conclusion: WSS remains a critical patient safety issue in Türkiye, particularly in orthopedic and high-volume surgical settings. Findings suggest that existing protocols alone are insufficient; effective implementation, regular audits, mandatory time-out compliance, and strengthening safety culture through structured training programs are essential for prevention.

Keywords

• Wrong-Site Surgery
• Patient Safety
• Surgical Safety Checklist
• Medico-Legal Analysis

Ameliyathaneden Mahkeme Salonuna: Yanlış Taraf Cerrahisi

Öz

Giriş: Türkiye’de yanlış taraf cerrahisi olgularının yüksek yargı kararları ve basına yansıyan haberler üzerinden analiz edilmesi ve hasta güvenliği ile hukuki boyutlarının ortaya konulmasıdır. Gereç ve Yöntem: 2010-2025 yıllarını kapsayan taramada lexpera.com.tr ve news.google.com kullanılarak toplam 22 olgu incelendi. Tanımlayıcı istatistikler SPSS v21.0 ile analiz edildi. Bulgular: Olguların %45,5’i ortopediye ait olup, alt ekstremite (%31,8) ve üst ekstremite (%22,7) en sık etkilenen bölgelerdi. Yanlış taraf cerrahisi en fazla kamu hastanelerinde görüldü (%45,5). Üst mahkemelerce hekim lehine yerel kararların hasta lehine bozulması dikkati çekti. Sonuç: Yanlış taraf cerrahisi önlenebilir bir hasta güvenliği sorunu olmasına rağmen ciddi klinik ve hukuki riskler barındırmaktadır. Protokollerin yanı sıra etkin uygulama, düzenli denetim, zorunlu eğitimler ve güvenlik kültürünün güçlendirilmesi önerilmektedir.

Anahtar Kelimeler

• Yanlış Taraf Cerrahisi
• Hasta Güvenliği
• Cerrrahi Güvenlik Protokolü
• Tıbbi Uygulama Hatası

Kaynakça

1. 1.Walker LE, Shapiro D, Akl S. Malpractice and Risk Management. Walker LE, Shapiro D, Akl S, editors. Introduction to Forensic Psychology: Clinical and Social Psychological Perspectives. 2020;365-73. [Crossref]
2. 2.Alim Usemahu S, Dame Panjaitan J. Analyst Types of Malpractice In Health Law. Int J Soc Res. 2024 June 22;2(3):130-40. [Crossref]
3. 3.Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual. 2023 June 22;12(2):e002264. [Crossref]
4. 4.Moshtaghi O, Haidar YM, Sahyouni R, Moshtaghi A, Ghavami Y, Lin HW, et al. Wrong‐Site Surgery in California, 2007‐2014. Otolaryngol--head neck surg. 2017 July;157(1):48-52. [Crossref]
5. 5.Lee SH, Kim JS, Jeong YC, Kwak DK, Chun JH, Lee HM. Patient Safety in Spine Surgery: Regarding the Wrong-Site Surgery. Asian Spine J. 2013;7(1):63. [Crossref]
6. 6.DeVine JG, Chutkan N, Gloystein D, Jackson K. An Update on Wrong-Site Spine Surgery. Glob Spine J. 2020 Jan 1;10(1_suppl):41S-44S. [Crossref]
7. 7.DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding Wrong Site Surgery: A Systematic Review. Spine. 2010 Apr 20;35(9S):S28. [Crossref]
8. 8.Tan J, Ross JM, Wright D, Pimentel MPT, Urman RD. A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery. Jt Comm J Qual Patient Saf. 2023 May 1;49(5):265-73. [Crossref]

9. 9.Gadelkareem RA. Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 1. Urological Wrong-Surgery Catastrophes and Disabling Complications. Curr Urol. 2018 Feb;11(2):73-8. [Crossref]
10. 10.Maloley L, Morgan LA, High R, Suh DW. Wrong-Site Surgery in Pediatric Ophthalmology. J Pediatr Ophthalmol Strabismus. 2018 May 1;55(3):152-8. [Crossref]
11. 11.Christensen JD, Hutchins GC, McDonald CJ. Computer automated detection of head orientation for prevention of wrong-side treatment errors. AMIA Annu Symp Proc. 2006;2006:136-40.
12. 12.Sağlık Hizmetleri Genel Müdürlüğü, Sağlıkta Kalite ve Akreditasyon Daire Başkanlığı. Güvenli Cerrahi Uygulama Rehberi [Internet]. 2. Baskı. Ankara; 2015 [cited 2025 Aug 25]. Available from: https://dosyamerkez.saglik.gov.tr/Eklenti/3741/0/4guvenlicerrahirehberipdf.pdf
13. 13.Safe surgery [Internet]. [cited 2025 Aug 25]. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery
14. 14.WHO Patient Safety, World Health Organization. WHO guidelines for safe surgery 2009: safe surgery saves lives. Safe surgery saves lives. 2009 Dec 31 [cited 2025 Aug 23]. Available from: https://www.who.int/publications/i/item/9789241598552
15. 15.Vacheron CH, Acker A, Autran M, Fuz F, Piriou V, Friggeri A, et al. Insurance Claims for Wrong-Side, Wrong-Organ, Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10 Years. Journal of Patient Safety. 2023 Jan;19(1):e13. [Crossref]
16. 16.Taylor MA, Yonash RA. Risk Factors for Wrong-Site Surgery: A Study of 1,166 Reports of Informed Consent and Schedule Errors. Patient Safety [Internet]. 2024 July 31 [cited 2025 Aug 26];6(1). Available from: https://patientsafetyj.com/article/117084-risk-factors-for-wrong-site-surgery-a-study-of-1-166-reports-of-informed-consent-and-schedule-errors[Crossref]
17. 17.T.C. Sağlık Bakanlığı, Sağlık Bilgi Sistemleri Genel Müdürlüğü. Sağlık İstatistikleri Yıllığı - 2023 [Internet]. Ankara; 2025. 196 p. Available from: https://www.saglik.gov.tr/TR-84930/saglik-istatistikleri-yilliklari.html
18. 18.Van Schoten SM, Kop V, De Blok C, Spreeuwenberg P, Groenewegen PP, Wagner C. Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands. BMJ Open. 2014 July;4(7):e005075. [Crossref]
19. 19.Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009 Jan 29;360(5):491-9. [Crossref]
20. 20.Papadakis M, Meiwandi A, Grzybowski A. The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety. Int J Surg. 2019 Sept 1;69:19-22. [Crossref]
21. 21.Gloystein DM, Heiges BA, Schwartz DG, DeVine JG, Spratt D. Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-Center Review of 487 Cases. Front Surg [Internet]. 2020 Oct 23 [cited 2025 Aug 26];7. Available from: https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2020.563337/full[Crossref]