A Case Report to Explore A Wrong-Site Surgery Error.

AORN JSep 29, 2026
Case ReportOrthopedic SurgeryGeneral Surgery

Rodney W Hicks, Hung-Fu Charlie Lin

✦ AI-curated · Sources linked

Case in brief

A case of wrong-site surgery involved an incorrect nerve block performed during a nonemergent orthopedic procedure. Despite some verification steps being completed, the incident was attributed to lapses in established workflows, communication failures, and incomplete verification of laterality. The situation was resolved by addressing these vulnerabilities and emphasizing adherence to safety protocols.

Diagnostic / clinical pearl

Clinicians should ensure rigorous adherence to established verification processes and maintain effective communication to prevent wrong-site surgery.

Why it matters

This case underscores the importance of system-level safeguards and vigilance in perioperative settings to mitigate the risk of sentinel events like wrong-site surgery.

Source

PubMed · PMID 42804530

Published in AORN J. This summary was written by xxcode from the publication's abstract and metadata. It is not peer reviewed and is not a substitute for the original article. For clinical decisions, review the original publication.

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