Conclusion
The majority of our surgical personnel experienced near misses and failures with regard to patient identity, surgical site, and/or procedure. Routines for ensuring correct patient, correct site, and correct surgical procedure were practised significantly differently by medical professionals, supporting our hypothesis. Identity check must involve all surgical team members with regard to their own medical objectives and also as a joint team responsibility. As raised awareness about near misses and inconsistent safety systems in the operating room enhances positive attitudes towards protocols, implementation of a Time Out protocol was welcomed.
We find that the study results of near-miss experiences with failure to confirm the patient identity, wrong patient being brought into the operating room, positioning of the patient on the wrong side and preparing for wrong procedures are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.