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Surgery performed at the incorrect anatomical site can be devastating for both patients and surgeons.1 We wish to highlight the case of a patient who had been correctly marked for surgery on the left hand with an arrow on the left forearm (Fig. 1: taken at the end of the procedure) who was found to also have an erroneous arrow on the right thumb (Fig. 2). On questioning the patient, it became clear that the arrow had become imprinted on the thumb when the patient had crossed his or her hands. Transfer of the mark not only introduces an erroneous mark, but also fades the correct mark.
The American Academy of Orthopedic Surgeons estimated that an orthopaedic surgeon has a 1 in 4 chance of performing wrong-site surgery during a 35-year career.2 Although there are anecdotal stories of transferred site marks we have identified only one previously published instance.3 This was in a patient whose mark was transferred from the forehead onto the bar of a slit lamp and then onto the brow of the next patient to use the lamp.
The use of marker pens does present a small risk in these circumstances of which all users should be aware. Guidelines on pre-operative marking have been produced by The Royal College of Surgeons of England in conjunction with the National Patient Safety Agency4 and feature in the World Health Organization's Surgical safety checklist.5