There were 63 incidences in the last three years where surgeons operated on the wrong part of a person's body.
New figures show that since 2017, the number of people experiencing this "nightmare" scenario is on the rise.
The information was released to the Irish Examiner by the HSE under the Freedom of Information Act.
It shows that surgeons operated on the wrong body part of 15 patients in 2017, 19 in 2018, and 22 last year.
Stephen McMahon from the Irish Patients Association said that of the 300,000 hospital admissions in Ireland each year, around 40,000 can have an adverse event, of which 28,000 are preventable.
Mr McMahon told the Moncrieff programme: "The numbers are quite small but for the patients involved it may have life-changing impacts.
"At the end of the day, the numbers are going up and we need to understand why that is happening.
The WHO has been looking at the issue of 'wrong site surgery' in recent years, with checklists provided to surgeons and healthcare workers to know exactly what they need to do.
He added it can be "a terrible journey" for a patient or their family to try and find out the truth after something goes wrong.
Mr McMahon said: "The most important thing if something happens to a patient is that they are told.
"Let's not forget that we're spending over €20bn on our health system and I think the least we can expect that with the 28,000 preventable errors, we need to get on top of that."
He said the HSE need to explain the causes behind such events, such as overworked staff.
"I want to reach out to the healthcare workers, they're all doing a great job and trying their best," Mr McMahon stated.
"But is the system actually listening to itself, do we have to be always having the tragedy and then the change.
"There needs to be a prevention process there rather than waiting for something tragic to happen."
In a statement to Newstalk, the HSE said: “It is the policy of the HSE that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services.
"The HSE has in place systems and processes to identify, report and investigate matters and address incidents that arise when delivering healthcare to patients.
“Services are continually engaged towards identifying areas where incidents are likely to occur and putting in place systems to prevent or reduce the likelihood of the risk of their occurrence.”
