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BMJ Case Rep. 2010; 2010: bcr11.2009.2489.
Published online 2010 February 8. doi:  10.1136/bcr.11.2009.2489
PMCID: PMC3028197
Learning from errors

Preoperative surgical marking: a case of seeing double


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.

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