Factors associated with wrong site surgery
| Active | |
| Problems with marking | Failure to mark |
| Wrong side/site marked | |
| Both sides marked | |
| Problems with consent | Patient consented to wrong procedure/site/side |
| Language difficulties | |
| Patient consented for procedure already performed or after surgery | |
| Problems with preparation/positioning | Preparation of wrong side/site |
| Preparation for wrong procedure | |
| Patient wrongly draped | |
| Tourniquet put on wrong side | |
| Patient wrongly positioned | |
| Measurement problems/failures | Measurements wrongly recorded |
| Wrong measurements taken | |
| Measurements misread | |
| Anaesthetic problems/failures | Patient anaesthetised early (before consultant has talked to patient) |
| Anaesthetic given from unfamiliar position resulting in wrong side | |
| Latent | |
| Wrong patient | Patient answers to wrong name |
| Problems with theatre lists | Wrong side/site/procedure typed on list |
| Theatre list changed at last minute | |
| Problems with notes | Missing notes, duplicate note |
| Notes wrongly written up | |
| Transcription errors | |
| Correct patient but wrong notes | |
| Problems with x rays | x Rays wrongly labelled |
| x Rays put up wrong way round | |
| No x rays | |
| Work pressures | Interruptions between operations |
| Time pressures | |
| Loss of concentration | |
| Failure of communication within hospitals | Failure of communication between staff/wards/theatre |
| Failure of communication between different departments | |
| Failure of communication between hospitals | Patient had procedure different from that promised at original hospital |
| Patient seen elsewhere privately with different procedures or different equipment | |