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An “Innocent” Wrong Surgery Is Rare with Precautions in Place to Prevent Missouri Medical Malpractice

Mistakes are entirely too common in the operating room, but they might not be as innocent as they appear. A national regulating agency has so many precautions in place to prevent these mistakes that it's difficult to assume a doctor's innocence when something still goes wrong.

The Joint Commission, an accrediting body for hospitals nationwide, is widely recognized for the high standards it demands to ensure quality care for patients. In 2003, the Joint Commission established a Universal Protocol for Preventing Wrong Site, Wrong Surgery, Wrong Person Surgery. 

This universal protocol is followed by most hospitals and requires a surgical team to take three specific precautions to prevent mistakes:

  1. Confirm the correct surgery with the patient before the operation begins
  2. Mark the spot of the surgery
  3. Take a “time out” just before surgery to communicate what exactly is to be done and avoid medical malpractice in Missouri and nationwide


The surgical team is expected to verify who the patient is and what he or she is having done at numerous points along the way, including:

  • When the surgery is scheduled
  • When any pre-surgery testing is conducted
  • When the patient is admitted for the surgery
  • When the patient goes in for surgery preparation
  • When the patient goes into the operating room
  • Anytime the patient's care is transferred to a new nurse or doctor


Once the patient is unconscious, the surgeon can still rely on visible markings to make sure the operation is done at the right spot. The location of the incision is supposed to be marked:

  • At the site of the intended surgery
  • With a marker that is visible even after surgery preparation
  • In a spot that can be seen when the patient is prepped for surgery
  • When the patient is awake

Time Out

This refers to a final pause just before surgery where the surgeon and each member of his team confer together to make sure that they are performing the right surgery on the right person. The time out:

  • Is a brief conversation that occurs moments before the operation begins
  • Includes the surgeon and every member of his team
  • Provides a final verification of the patient's identity
  • Confirms the correct procedure and location of the surgery one last time

With so many precautions in place, it's almost impossible to make an innocent mistake on what surgery is to be done. If the entire process is followed correctly, any mistakes should be caught right away and corrected.

If you or a family member has been the victim of a wrong surgery, it's possible that someone on the surgical team failed to follow this required process. If so, you may have a case for a Missouri medical malpractice lawsuit.

For a free consultation with an experienced Missouri medical malpractice attorney, call Alvin Wolff at 314-241-2500. We'll also give you a free copy of our book, The Guide on How to Pick a Lawyer.