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Ann R Coll Surg Engl. 2009 July; 91(5): 444–445.
PMCID: PMC2758467

Transfer of a Pre-Operative Surgical Site Mark to the Opposite Side Increases the Risk of Wrong Site Surgery

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.

Figure 1
Left forearm correctly marked with an arrow.
Figure 2
Arrow transferred to right thumb.

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


1. Dyer C. Surgeons cleared of manslaughter after removing wrong kidney. BMJ. 2002;325:9. [PMC free article] [PubMed]
2. American Academy of Orthopedic Surgeons. Wrong Site Surgery. <> [Accessed 22 March 2008]
3. Lambley RG, Herbert EN. Preoperative site marking for eye surgery may be transferred from patient to patient or moved, increasing the potential for wrong site surgery. Br J Ophthalmol. 2008;92:295. [PubMed]
4. The Royal College of Surgeons of England and the National Patient Safety Agency. Patient safety alert 06; Pre-operative marking recommendations. <>.
5. World Health Organization. Surgical safety checklist. <>.

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England