Risk Factors for Wrong Site Surgery

Was there an absence of or breakdown in the system to verify the surgical site, including the use of a checklist?

Are there patients with similar names?

Are abbreviations being used?

Was 'right' used to mean correct?

Does the patient have a proper identification band?

Are hospital beds being moved around a lot?

Was the patient or representative involved in the process of identifying the correct site?

Is there a problem with the marking of the operative site (lacking, ambiguous, etc)?

Have there been late or last minute changes to the operating room schedule?

Was a final check performed in the operating room prior to starting the case?

Was everyone in the operating room involved in the verification process?

Did the surgeon check patient details prior to starting the procedure?

Was more than one surgeon involved with the case?

Is the patient's medical record in the operating room?

Are there medical records from other patients in the operating room?

Is this an unplanned emergency case?

Is there a heavy operating room workload for available staff?

Are multiple procedures being performed on the same patient?

Do patient characteristics require a change in positioning (morbid obesity, unusual anatomy)?

Is the case occurring during a disaster?

Does the surgeon have procedures going on in multiple rooms simultaneously?

Is the patient able to respond but not able to think clearly?

Is there miscommunication due to a language barrier?

Is the surgeon new or inexperienced?

Are there new or inexperienced operating room personnel?