Wrong-site craniotomy: analysis of 35 cases and systems for prevention

Clinical article

Restricted access


The purpose of this case review was to identify and analyze existing wrong-site craniotomy (WSC) cases to determine the factors that contributed to the errors and to suggest preventative strategies for WSC. Wrong-site surgery (WSS) is a devastating surgical error that has gained increased public attention in recent years due to some high-profile cases. Despite the implementation of preventative methods such as preoperative checklists and surgical time-outs, WSS still occurs to this day. The clinical consequences of WSC are distinct compared with other types of WSS due to the unique function of the brain.


The authors searched medical, legal, and media databases and contacted state medical licensing boards to identify and gather information about WSC cases. The cases were reviewed and analyzed for factors that contributed to the errors.


Four major categories of contributing factors were found: 1) communication breakdown; 2) inadequate preoperative checks; 3) technical factors and imaging; and 4) human error. The WSC cases are used to illustrate how these types of factors can precipitate the surgical error. Clinical outcomes and disciplinary actions are summarized. Obtaining information about the cases discovered was very challenging, in part because WSS reporting is inadequate.


This case review demonstrates that a broad range of events and factors can cause human errors to breach patient safeguards and lead to a WSC; however, in essentially all cases the WSCs were preventable with strict adherence to comprehensive and thorough protocols.

Abbreviations used in this paper: JCAHO = Joint Commission on Accreditation of Healthcare Organizations; OR = operating room; WSC = wrong-site craniotomy; WSS = wrong-site surgery.
Article Information

Contributor Notes

Address correspondence to: Mark Bernstein, M.D., M.H.Sc., F.R.C.S.C., Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada. email: mark.bernstein@uhn.on.ca.Please include this information when citing this paper: published online December 18, 2009; DOI: 10.3171/2009.10.JNS091282.

© AANS, except where prohibited by US copyright law.

  • From the Editor-in-Chief: The references in this article are not provided in the standard format. The present format was used to protect the patients, surgeons, and hospitals. Abbreviations: XXX = surgeon's name; YYY = hospital's name; ZZZ = patient/family's name.

  • 1

    A surgeon's nightmare: brain-operation error ‘was worst moment of my life.’. Spokane Daily Chronicle November151980

  • 2

    Allison W: Neurosurgeon fined for ‘wrong-side’ mistake. St. Petersburg Times December32000

  • 3

    Altman LK: State fines YYY for an error in brain surgery. New York Times March91996

  • 4

    Altman LK: State issues scathing report on error at YYY. New York Times November161995

  • 5

    American College of Surgeons Committee on Processes of Surgical Care American College of Surgeons Member Services Liaison Committee: Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg 87:262002

    • Search Google Scholar
    • Export Citation
  • 6

    Baker SPQiang YRebok GWLi G: Pilot error in air carrier mishaps: longitudinal trends among 558 reports, 1983–2002. Aviat Space Environ Med 79:262008

    • Search Google Scholar
    • Export Citation
  • 7

    Bernhard B: YYY performs wrong-site surgery. Orange County Register June122007

  • 8

    Bernstein M: Surgical planning error: what's in a name?. Lancet 362:9082003

  • 9

    Bernstein M: Wrong-side surgery: systems for prevention. Can J Surg 46:1441462003

  • 10

    Blackhurst D: Doctors cut into wrong side of my head. The Sentinel December282007

  • 11

    Board of Medical Licensure and Discipline: In the matter of XXX. MD XXX:MD090272007

  • 12

    Brain surgeon who made mistake is reinstated. New York Times October41995

  • 13

    Center treats wrong side of patient's brain. Patient treated at cancer center.October302007. (http://www.newsnet5.com/print/14455533/detail.html) [Accessed November 13 2009]

  • 14

    Christensen JDHutchins GCMcDonald CJ: Computer automated detection of head orientation for prevention of wrong-side treatment errors. AMIA Annu Symp Proc 2006:136 1402006

    • Search Google Scholar
    • Export Citation
  • 15

    Circuit Court Harrison County M. ZZZ v. XXX M.D. and XXX M.D. Cause #A2401-2001-004042004

  • 16

    Circuit Court of Pulaski County A. ZZZ vs. The Medical Assurance Company Inc. Case # CV 09-962006

  • 17

    Cowan JA JrChandler WF: Changing trends in the use and costs of procedures performed by neurosurgeons in the United States. Clin Neurosurg 54:2092112007

    • Search Google Scholar
    • Export Citation
  • 18

    DiJoseph S: California hospital announces new rules after opening wrong side of child's skull during brain surgery April12006. (http://www.newsinferno.com/archives/1038) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 19

    Doctor opens wrong side of skull in emergency brain surgery. Associated Press September221995

  • 20

    Doctor who cut off wrong leg is defended by colleagues. New York Times September171995

  • 21

    Doctors perform surgery on wrong side of woman's head. Japan Times September102007

  • 22

    Donaldson L: 2007 Annual Report of the Chief Medical Officer: While You Were Sleeping Making Surgery Safer.2008. (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086180.pdf) [Accessed November 13 2009]

  • 23

    Florida Department of Administrative Hearings. Department of Professional Regulation Board of Medical Examiners v. XXX. Case #1984 WL 2751541984

    • Export Citation
  • 24

    Freyer FJ: R.I.H. doctor operates on wrong side of brain. Providence Journal August22007

  • 25

    Hancock County man award over $1.4 million in civil suit (http://www.msverdict.com/john-d-giddens-law-frim-mississippi-jackson-in-the-news.html) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 26

    Haynes ABWeiser TGBerry WRLipsitz SRBreizat AHDellinger EP: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:4914992009

    • Search Google Scholar
    • Export Citation
  • 27

    Hospital malpractice cases up 4-fold in FY 2002. Japan Economic Newswire September122003

  • 28

    Hospital sued over botched brain surgery. United Press International June82005

  • 29

    Indiana State Department of Health: Title 410 LSA Document #05-326(E). Indiana State Department of Health 2006 (http://www.in.gov/legislative/iac/xml/old-ir/Vol29/04Jan/06E410050326.PDF) [Accessed November 13 2009]

  • 30

    Jhawar BSMitsis DDuggal N: Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 7:467 4722007

  • 31

    Joint Commission: A Follow-Up Review of Wrong Site Surgery Sentinel Event Alert December 5 2001 (http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 32

    Joint Commission: Implementation Expectations for the Universal Protocol for Preventing Wrong Site Wrong Procedure and Wrong Person Surgery Joint Commission 2003 (http://www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8C-FEBA74A732EA/0/up_guidelines.pdf) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 33

    Joint Commission: Speak Up. The Universal Protocol for Preventing Wrong Site Wrong Procedure and Wrong Person Surgery 2009. (http://www.jointcommission.org/NR/rdonlyres/F8046F2C-A8A2-412F-88D4-E1762BCC5C26/0/UP_Poster.pdf) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 34

    Katz C: New York man to sue hospital, doctors over brain surgery mistake. Daily News (New York) March12001

  • 35

    Kennedy K: Surgeons made big error, 2 patients' lawsuits allege. Chicago Tribune June92005

  • 36

    Man accuses hospital of operating on wrong side of his brain. Associated Press State & Local Wire August51999

  • 37

    Man awarded damages for brain surgery error. Associated Press February122004

  • 38

    Man dies after surgeon operates on wrong side of head. Associated Press August242007

  • 39

    Man sues over brain surgeon's error. Toronto Star January271991

  • 40

    McFadden RD: 2 doctors suspended after surgery on wrong side of man's brain. New York Times February262001

  • 41

    Mello F: Wrong-site surgery case leads to probe: 2nd case of error at R.I. hospital this year. Boston Globe August42007

  • 42

    Minnesota Department of Health: Adverse Health Events Reporting Law: Minnesota's 28 Reportable Events MDH Division of Health Policy 2007 (http://www.health.state.mn.us/patientsafety/ae/adverse27events.html) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 43

    Moritz O: Hospital fined in brain op blunder. New York Daily News December62001

  • 44

    National Patient Safety Agency: Rapid Response Report 9: Avoiding wrong side burr holes/craniotomy National Patient Safety Agency 2009 (http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/craniotomy/) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 45

    New York State Board for Professional Medical Conduct: In the matter of XXX M.D. Order # BMPC 96-1471996

  • 46

    NHS blunders revealed by release of records. Telegraph. September 24 2007

  • 47

    Patient Safety Authority: Pennsylvania Patient Safety Authority 2008 Annual Report Patient Safety Authority2009. (http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/annual_report_2008.pdf) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 48

    Refuse work with surgeon. Bulletin Journal. November 16 1980

  • 49

    Saufl NM: Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. J Perianesth Nurs 19:3483512004

  • 50

    Shaver K: Hospital changes operation procedure. St. Petersburg Times March21995

  • 51

    Shillito J Jr: “Confusion tomography”. Surg Neurol 19:554 5551983

  • 52

    Smith MR: Brain surgery goes awry in R.I. Associated Press.December142007

    • Export Citation
  • 53

    Smith MR: Oops: big egos blamed for brain surgery mistakes. Associated Press.December152007

    • Export Citation
  • 54

    State of Colorado Board of Medical Examiners. In the matter of the disciplinary proceeding regarding the license to practice medicine in the State of Colorado of XXX M.D. Case # ME 2005-2005

  • 55

    State of Connecticut Department of Public Health Bureau of Regulatory Services. In re: XXX M.D. Consent Order. Petition #951010-01-1961996

  • 56

    State of Florida Agency for Health Care Administration Florida Center for Health Information and Policy Analysis: Risk Management and Patient Safety Program. Medical Errors Resolution and Tracking Programs: Hospital and Ambulatory Surgical Centers. Florida Agency for Health Care Administration 2009 (http://www.fdhc.state.fl.us/SCHS/risk/index.shtml) [Accessed November 13 2009]

  • 57

    State of Florida Board of Medicine. Department of Health vs. XXX M.D. Case #1998-101872000

  • 58

    State of Florida Board of Medicine. Department of Health vs. XXX M.D. Case #2002-054362005

  • 59

    State of Florida Board of Medicine. Department of Health vs. XXX M.D. Case #2002-255672005

  • 60

    State of Florida Board of Medicine. Department of Health vs. XXX M.D. Case #2006-209292007

  • 61

    State of Wisconsin Medical Examining Board. In the matter of the license of XXX M.D. #95 MED 423 97 MED 201 98 MED 832003

  • 62

    State says hospital made mistakes before botched brain surgery. Associated Press.November161995

    • Export Citation
  • 63

    Steinhauer J: Surgeon treated wrong side of two brains, Albany says. New York Times March12000

  • 64

    Sterling TG: Drawing from the wrong side of the brain. Phoenix New Times January141999

  • 65

    Stone SBernstein M: Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery 60:107510822007

    • Search Google Scholar
    • Export Citation
  • 66

    Strelec SR: Anesthesia and surgery: not always a one-sided affair. ASA Newsl 60:61996. (http://www.asahq.org/Newsletters/1996/06_96/feature4.htm) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 67

    Supreme Court of Iowa. XXX v. Anesthesiologists of Cedar Rapids YYY and YYY. Case #333 N.W.2d 4511983

  • 68

    Surgeon axed over botched operation. United Press InternationalSeptember11995

  • 69

    Surgeon drills on wrong side of head. Daily Vidette.January172002

  • 70

    Surgeon's license restored after wrong-side brain procedure October172007. (http://www.digitaljournal.com/print/article/240803) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 71

    Tanzania ‘sorry’ for surgery mix-up November142007. (http://news.bbc.co.uk/2/hi/africa/7094517.stm) [Accessed November 13 2009]

  • 72

    Tanzanian who had wrong surgery dies November232007. (http://news.bbc.co.uk/2/hi/africa/7109392.stm) [Accessed November 13 2009]

  • 73

    Tsao E: Doctor saws through wrong side of patient's skull. Associated Press Worldstream September221995

  • 74

    Tsao E: Hospital investigates brain operation. Associated Press September221995

  • 75

    Tubbs C: Suit claims surgeon started on wrong side of boy's skull. Arkansas Democrat Gazette July222005

  • 76

    United States Census Bureau: United States Census 2000 data releases U.S. Census Bureau2000. (http://www.census.gov/main/www/cen2000.html) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 77

    United States Nuclear Regulatory Commission: Medical event involving a dose that is different than prescribed (http://www.nrc.gov/reading-rm/doc-collections/event-status/event/2009/20090528en.html) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 78

    Walters K: Judge orders area doctor to pay $810K 2004. (http://www.msverdict.com/john-d-giddens-law-frim-mississippi-jackson-in-the-news.html) [Accessed November 13 2009]

    • Search Google Scholar
    • Export Citation
  • 79

    Wrong-sided brain surgery trial halted over possible juror misconduct. PR Newswire May22008

  • 80

    YYY fined for 3rd wrong-side surgery this year. Associated Press.November262007

  • 81

    YYY hospital adopts new rules following surgery gaffe. Associated Press State & Local Wire.March312006

  • 82

    YYY reprimanded for wrong site surgeries.November272007. (http://www.injuryboard.com/national-news/rhodeisland-hospital-reprimanded-for-wrong-site-surgeries.aspx?googleid=28640) [Accessed November 13 2009]



All Time Past Year Past 30 Days
Abstract Views 593 584 25
Full Text Views 326 162 1
PDF Downloads 91 66 0
EPUB Downloads 0 0 0
Google Scholar