Wrong-Side/Wrong-Site/Wrong-Procedure/Wrong-Patient

Ken Margolin

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Although wrong-side/wrong-site/wrong-procedure/wrong-patient (WSPE) hospital errors are not common, they occur more often than one would expect. As the phrase implies, WSPE typically means that the right patient has been operated on the wrong side or organ, or that the correct procedure was done - correct for a patient other than the one on whom it was performed. When WSPEs occur, the results are often devastating.

Medical professionals seeking to reduce medical negligence and medication errors, are analyzing WSPEs as a means to better understand how catastrophic medical errors occur. Common to many WSPEs is a sequence of events termed the "error chain." The error chain is a series of breakdowns of procedures and communication, that culminate in a medical error. Some error chains have been identified as having resulted from a "normalization of deviance." Vaughan D., The Challenger launch decision: risky technology, culture and deviance at NASA. Chicago, IL: University of Chicago Press; 1996.

Normalization of deviance occurs when the abandonment of sound practices becomes the norm, because the personnel involved have gotten away with cutting corners, and come to believe that safer, but more burdensome practices, are unnecessary. The defense of "we've always done it that way, and never had a problem," is misguided. It often takes a catastrophe to reveal the hazards inherent in placing efficiency and savings over safety.