Table 2

 Factors associated with wrong site surgery

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