Wrong site surgery

1 Although among the pantheon of medical errors it is relatively rare, the consequences can be disastrous-for example, removing the wrong eye when its fellow is blind. Because of the potentially serious nature of this error, a number of organisations have focused their efforts in reducing the occurrence. Similar patient names Use of abbreviations Using "right" for correct Patients not "labelled" (usually a wristband) on admission Hospital beds being moved around Failure to include the patient (or their relatives or carers) in the process of identifying the correct site Operation site not marked or unclearly marked (for example, using an "X" to mark may suggest that this is the side to be done or equally the side not to be done) Late changes to operating lists Lack of a final check in the operating theatre Lack of involvement of all theatre staff in the identification process Not bringing patient notes or investigations to theatre (and conversely removing the notes from theatre of the previous patient to avoid confusion) Surgeon not rechecking patient details before starting the operation Lack of a checklist to make sure every check had been performed Involvement of more than one surgeon Time pressures (for example, unplanned emergencies or larger volume lists) Performance of multiple procedures in the same patient Patient characteristics, such as obesity or unusual anatomy, that lead to alterations in the usual positioning of the patient.