From the Operating Room to the Courtroom: Wrong-Site Surgery

Introduction: Wrong-site surgery (WSS) is considered a “never event” and represents a serious and fully preventable patient safety issue. Despite international protocols, these incidents continue to occur, leading to significant clinical, legal, and social consequences. This study aimed to analyze wrong-site surgery cases reported in Supreme Court decisions and the media in Türkiye, identifying their characteristics and legal implications from a forensic medicine perspective. Material Methods: A retrospective review was conducted using the legal database lexpera.com.tr and Google News search engine. Keywords such as “wrong-side surgery” and equivalent Turkish terms were used to identify cases between 2010 and 2025. A total of 22 cases meeting inclusion criteria were analyzed. Descriptive statistics were performed using SPSS v21.0. Results: Among the 22 cases, 45.5% involved orthopedic surgery, followed by ophthalmology and general surgery (each 13.6%). The most common surgical sites were lower (31.8%) and upper extremities (22.7%). Wrong-site surgery was most frequently reported in public hospitals (45.5%), followed by university/research hospitals (31.8%). Legal analysis revealed that several decisions initially favoring physicians at local courts were overturned in Supreme Courts, mostly in favor of patients, indicating significant medico-legal risk. Conclusion: WSS remains a critical patient safety issue in Türkiye, particularly in orthopedic and high-volume surgical settings. Findings suggest that existing protocols alone are insufficient; effective implementation, regular audits, mandatory time-out compliance, and strengthening safety culture through structured training programs are essential for prevention.