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Logo of bmjcrInstructions for authorsCurrent ToCBMJ Case Reports
BMJ Case Rep. 2010; 2010: bcr11.2009.2489.
Published online Feb 8, 2010. doi:  10.1136/bcr.11.2009.2489
PMCID: PMC3028197
Learning from errors
Preoperative surgical marking: a case of seeing double
Milap Rughani,1 Michail Kokkinakis,2 and Marc Davison3
1John Radcliffe Hospital, Plastic Surgery, Headington, Oxford OX3 9DU, UK
2Buckinghamshire Hospitals NHS Trust, Trauma and Orthopaedics, Mandeville Road, Aylesbury HP21 8AL, UK
3Buckinghamshire Hospitals NHS Trust, Department of Anaesthetics, Mandeville Road, Aylesbury HP21 8AL, UK
Correspondence to Milap Rughani, mrughani/at/
Preoperative marking is an integral part of the care of patients undergoing surgical procedures. It occurs on a daily basis in hospitals and involves all members of the healthcare staff and the patient. Incorrect marking or errors can lead to devastating consequences for the patient and staff involved. We present an unusual case of seeing double arrows on a patient undergoing emergency orthopaedic surgery, despite standard preoperative marking procedures. This was recognised in the anaesthetic room and the correct site was confirmed. We aim to highlight this specific problem and remind all involved in preoperative marking of the dangers of a mirror imprint, thereby avoiding seeing double in the anaesthetic or operating room.
Since 2001 the National Patient Safety Agency (NPSA) has reported 59 cases of patient safety incidents relating to incorrect patient site or procedures.1 The results of these errors can be devastating for the patient and staff and have major clinical, psychological and legal repercussions. Subsequently the NPSA in association with the Royal College of Surgeons (RCS) have developed recommendations for preoperative marking (including who, when, and where to mark). This has been further endorsed by the Joint Commission on Accreditation of Healthcare Organisations (JCHO)2 and the American College of Surgeons.3 This has now been carried forward to become one of the core safety checks in the World Health Organization Surgical Safety Checklist.4
We present an unusual case where despite the implementation of a preoperative marking protocol there was still confusion as to the surgical site for the procedure. We aim to highlight this specific problem and hope to use this as an example to all involved with preoperative marking, thus avoiding future mistakes.
Case presentation
A 65-year-old man sustained a right displaced ankle fracture. He was subsequently admitted to the acute trauma ward and underwent routine preoperative investigations. A member of the orthopaedic team obtained informed consent for an open reduction and internal fixation of his right ankle on the ward. The affected lower limb was marked using a standard permanent marker pen.
The following day the patient was brought to the operating theatre to undergo surgery. During the routine preoperative check in the anaesthetic room, two arrows were noted on the patient, on the medial aspect of each thigh (fig 1).
Figure 1
Figure 1
Duplication of preoperative marking from a permanent marker pen.
Outcome and follow-up
The operating surgeon was notified of the situation and correct site for surgery was confirmed from the patient, clinical notes and radiographs.
This case highlights a unique case for a standardised preoperative marking process. The marking was done on the ward with a red permanent marker pen. While the ink was still wet, the patient was able to bring both legs together and caused a “mirror like” imprint on the contralateral leg. At the time of surgery it was not clear which leg was the operative side based on the marking conducted preoperatively.
This scenario could also occur if placed on the lower legs or medial calf. Therefore we recommend that surgeons (or nominated deputies) should be made aware of the importance of marking surgical sites with consideration for any imprinting of the mark.
Ideally the patient should have had the checks before leaving the ward and the problem could have been avoided prior to entering the anaesthetic room. It could be assumed that patients are only asked if they have been “drawn on” and not specifically questioned which site and confirmation of the procedure they are set to undergo. This raises the notion of involving patients more in the preoperative marking process.
A study by DiGiovanni et al5 evaluated the compliance of patients in avoiding wrong site surgery by following specific preoperative instructions given to patients undergoing elective orthopaedic surgery. They reported that 59% were compliant with instructions; however, certain patients showed poor compliance. This trend was suggested to be associated with patient behaviour relying solely on the care of doctors and nurses. It is worth considering the role of patients in the preoperative marking process, thus increasing patient involvement and decision making in their care. We are aware of surgical guidelines, in development, in the Netherlands that also highlight this particular patient hazard (D Poldermans, personal communication).
Learning points
  • With the growing pressure of emergency cases on surgery departments and increasing throughput of patients, correct preoperative marking protocols should not be compromised.
  • However, multiple clauses in protocols cannot prevent this double marking from occurring. Appreciating the consequences of the arrow in our case report should be an important reminder to all involved of avoiding marking on areas where a mirror imprint of a mark can occur, and therefore avoid seeing double in the anaesthetic or operating room.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
1. National Patient Safety Agency Patient safety alert 06; March 2005.
2. Joint Commission on Accreditation of Healthcare Organisation Universal protocol for preventing wrong site, wrong procedure and wrong person surgery. JCHO 2006.
3. Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg 2002; 87: 12. [PubMed]
4. Humphreys G. Checklists save lives. Bull World Health Organ 2008; 86: 497–576.
5. DiGiovanni CW, Kang L, Manuel J. Patient compliance in avoiding wrong-site surgery. J Bone Joint Surg Am 2003; 85-A: 815–9. [PubMed]
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