ODP Wrong-Site Surgery Near Miss: Driscoll

What?

During a busy trauma list, a patient was anaesthetised for surgery on their left ankle. At the time out, the surgeon stated the operation and side, and I read back from the consent form as I always do. The consent form said left; the operating list, from which the theatre had been prepared, said right - and the limb prepped and draped was the right. I called the discrepancy. The team stopped, checked the original clinic letter and imaging, and confirmed the correct site was the left ankle. The patient was re-prepped, the list entry was corrected, and the operation proceeded on the correct side. An incident report was submitted and the case went to the theatre governance meeting.

So what?

What unsettles me most is how survivable the error chain was until the last barrier. The list was wrong, the preparation followed the list, the arrow from the ward marking had been partially obscured by the drapes, and the time out was happening - as it often does on a pressured trauma list - at speed, with half the team mid-task. If I had read the side from the list in front of me instead of the consent form, the readback would have agreed with the error. That detail is everything: the checklist step worked because it drew on an independent source of truth, not because it was performed. I felt a beat of real fear before I spoke - the surgeon was senior, the list was late, and 'stop' is a heavy word in that room - and I understand now, in a way I did not before, why near misses go unspoken. Afterwards the surgeon thanked me in front of the team, which cost him nothing and will make the next challenge, by anyone in that theatre, easier.

Now what?

I will keep anchoring my readback to the consent form and never to the list, and at governance I proposed we make that explicit in our local time out standard rather than leaving it to habit - the meeting agreed. I have also changed how I behave when I am not the one speaking: full stop-and-face during time out, because my own half-attention on other days was part of the same culture that nearly let this through. I am using this case, anonymised, in the induction session I deliver for new theatre staff, focusing on the independent-source principle and on how it feels to speak up, not just the rule that says you must.