Laterality Errors and Risk Reduction Across the Entire Care Pathway at an Ambulatory Day Surgery, 2013–2023

Incorrect side surgery is a cardinal healthcare “never event”, one so severe that strong governance and management protocols are universally implemented to eliminate risk. Their rarity can make quantifying the risk challenging, and their severity discourages open acknowledgement and review, with reportedly more wrong side events published in the lay press than in the medical literature. This retrospective study assessed the incidence of all laterality errors across the entire care pathway from initial consultation and consent to surgery, and was approved by RANZCO HREC (192.25). The aim was to identify process weaknesses that contribute to errors and reduce the risk of actual harm.

A review was performed of all laterality errors reported at an Australian Day Surgery from opening in November 2013 to December 2023. This is a private two-theatre facility for ophthalmic and dermatology surgery, with a safety learning system operating from inception to improve care without fault or blame. This nationally accredited facility ] can be considered representative of day surgeries that adhere to similar standards...