Wrong site surgery can occur as a result of errors in the handling of tissue specimens. Some mixups may go undetected while others can have serious consequences.
Wrong site surgery may occur as a result of:
(1) Mixup between multiple specimens in the same patient.
(2) Mixup in specimens between 2 patients.
(3) Mixup on orientation of a specimen.
Some examples:
(1) A patient with 2 colon polyps, one with cancer and one without.
(2) A woman with a biopsy from the left breast and a biopsy from the right breast
(3) Prostate biopsies from 2 patients, one with prostate cancer and one without.
(4) Additional tissue taken to clear a resection margin is taken from the wrong side.
A mixup may occur as a result of:
(1) incorrectly labeling specimens
(2) incorrectly processing and handling specimens
(3) incorrectly reading or dictating histologic slides or smears
(4) incorrectly typing a report
(5) confusing the orientation of a specimen
(6) a misunderstanding about the results
Examination of the original containers or slides can sometimes identify the cause.
If specimens are switched between 2 patients, then genetic testing can be performed on the specimens to establish origin.
If the locations of 2 switched specimens in the same patient are close together, then surgery may still be effective.
