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My husband went to the hospital to have his right kidney removed. Unfortunately, the wrong kidney was taken out. Now he is fighting for his life. Why do wrong-site surgical errors happen in Illinois hospitals?

As you know, surgery on the wrong body part can have life-threatening consequences. Because wrong site surgery is so risky, a set of rules called the Universal Protocol requires doctors to use a three-step process to prevent surgical errors.

Universal Protocol for Preventing Wrong-Site/Wrong-Patient Surgery

  1. Preoperative verification: The physician should check that the scheduled surgery matches the patient’s expectation and that the patient’s records are consistent with the surgical team’s understanding of the procedure to be performed. During this step, a team member should gather any missing information and check for discrepancies.
  2. Mark the operative site: The surgeon performing the procedure should mark the part of the body to be operated on while the patient is still awake and aware.
  3. Time out: Surgical teams must take a time out before surgery in order to verify that they are performing the correct procedure on the correct patient. Surgery should not begin until all concerns are resolved.


Wrong site and wrong procedure errors happen in Illinois hospitals when the Universal Protocol is rushed through, disrupted, or skipped. Common reasons why the Universal Protocol may not be followed include:

  • Mistakes on patient wristbands
  • Two patients with similar names
  • Hospital beds have been moved around
  • Unclear abbreviations on the medical chart
  • Using the term “right” instead of correct
  • Failure to ask the patient or patient representative about the surgical procedure
  • The operation site is not marked or not clearly marked
  • Last minute changes in the operating room schedule
  • Last minute changes in the operating room staff
  • Skipping the final verification or “time out” in the operating room
  • Surgeon does not verify the details of the procedure before beginning the operation
  • Lack of a checklist
  • Lack of involvement of all operating room staff in the verification procedure
  • Not bringing patient notes to the operating room
  • More than one surgeon is involved in the procedure
  • Time pressure due to over-scheduling or emergencies
  • Multiple surgical procedures in the same patient


The Universal Protocol exists to prevent operating room errors in Illinois operating rooms. When it is followed, wrong site procedures don’t happen. When it is not followed, medical staff put patient lives at risk. This is medical malpractice.

If someone you love was seriously injured or killed during a surgical procedure, contact the Gurnee personal injury attorneys at Hupy and Abraham. You have rights and you deserve justice. To schedule a free consultation, call 866-625-2299.


Jason F. Abraham
Managing Partner, Hupy and Abraham