Fraser and Adams listed a number of risk factors associated with wrong site surgery. The authors are from the Sunderland Eye Infirmary in England.
Risk factors for wrong site surgery:
(1) absence of or breakdown in the system to verify the surgical site, including use of a checklist
(2) patients with similar names
(3) use of abbreviations, especially when handwritten
(4) using "right" to mean correct
(5) patient without identification band
(6) hospital beds being moved around a lot
(7) failure to include the patient or representative in the process of identifying the correct site
(8) problem with marking of the operative site (lacking, ambiguous, etc)
(9) late or last minute changes to the operating room schedule
(10) failure to perform a final check in the operating room
(11) failure to involve all operating room personnel in the verification process
(12) failure of surgeon to check patient details prior to starting the procedure
(13) involvement of more than one surgeon
(14) failure to bring medical record for the patient into the operating room
(15) failure to remove records from a previous case from the operating room
(16) unplanned emergency cases
(17) heavy operating room workload for available staff
(18) multiple procedures to be performed on the same patient
(19) patient characteristics requiring a change in positioning (morbid obesity, unusual anatomy)
Additional risk factors (not given in the paper):
(1) disaster
(2) surgeon with procedures going on in multiple rooms simultaneously
(3) patient able to respond but not able to think clearly
(4) miscommunication due to language barriers
(5) new or inexperienced surgeon
(6) new or inexperienced operating room personnel
