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

Abstract

Wrong-site surgery (WSS) is a rare but preventable sentinel event with significant patient, professional, and organizational consequences. Despite longstanding safety standards, including the Universal Protocol, WSS continues to occur across procedural settings. This case report examines a wrong-side nerve block that occurred during a nonemergent orthopedic procedure. The case is discussed in the context of known patterns, contributing factors, and system failures associated with WSS. Key issues identified include deviations from established workflows, communication gaps, interruptions, incomplete verification of laterality, and failures to consistently apply policies and procedures at critical points in care. Although elements of the verification process were completed, the case highlights vulnerabilities in execution and timing, particularly before the initiation of a nerve block. Implications for perioperative nursing practice emphasize adherence to standardized processes, vigilance during workflow changes, effective team communication, and proactive system-level safeguards to reduce the ongoing risk of WSS.