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).
- 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.