Title : Getting the side right: Consent and pre-operative site marking compliance in trauma and orthopaedics
Abstract:
Background: Wrong-site surgery remains an NHS never event and is wholly preventable. The National Safety Standards for Invasive Procedures (NatSSIPs 2, NHS England 2022) require the operative site and laterality to be documented on the consent form and confirmed by indelible pre-operative site marking for every procedure with a definable side. Missing or incorrect laterality on the consent form or theatre booking list are recognised precursor (near-miss) events that erode the safety barriers protecting against wrong-site surgery; yet compliance is rarely measured objectively against imaging.
Aim: To assess compliance of consent form and theatre booking list laterality documentation with NatSSIPs 2 standards across trauma operating at BHRUT, to quantify the frequency and pattern of errors using the pre operative radiograph as the objective reference standard, and to identify targeted interventions to achieve full compliance.
Methods: A prospective observational near-miss audit was conducted across trauma theatres at Queen’s Hospital, Romford. All consecutive trauma and orthopaedic cases with a lateralised procedure were included. Documented laterality on the consent form and theatre booking list was compared against the pre-operative radiograph, which was used as the objective reference standard for the correct side. Data were analysed using descriptive statistics in Microsoft Excel.
Results: Seventy-one cases were reviewed. Consent form laterality was correct in 50 cases (70.4%), giving a documentation error rate of 29.6% (21/71): the wrong side was subsequently corrected in 9 cases (12.7%), and laterality documentation was incomplete in 12 cases (16.9%). Booking list laterality was correct in 64 cases (90.1%), giving an error rate of 9.9% (7/71). Two cases (2.8%) contained errors on both the consent form and booking list, representing the highest-risk near-misses that would not have been identified by cross-checking the documentation alone. Errors occurred on 13 of 14 operating days, and all were identified only through informal pre list radiograph review. No case met the NatSSIPs 2 target of a 0% error rate.
Conclusions: Consent and booking list laterality documentation fell substantially short of the NatSSIPs 2 standard, with errors distributed across nearly all operating days, indicating a systemic failure rather than isolated lapses. The only safeguard preventing these near-misses from reaching theatre was non-standardised, individual radiograph checking, leaving the pathway vulnerable, particularly in the two cases where both documents were incorrect. Recommended interventions include consent being taken by a clinician familiar with the procedure in the patient’s presence, a mandatory pre-list cross-check of consent and booking laterality against imaging, targeted teaching for junior doctors on laterality documentation, and a structured datix near-miss reporting pathway to achieve sustained improvement.
