| 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 |
