Marking the surgical site

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This should be an essential part of the process of preparing a patient for surgery. Failure of this process for whatever reason is disastrous for all involved. Sadly, like many medicolegal mistakes, the cynical maxim of "Not the first time, not the last time" applies and cases continue to surface intermittently.

The operating surgeon should personally see the patient and mark the patient himself. Even if this task is delegated, the courts are likely to hold the operating surgeon responsible if an error is made.

Good Practice

A system approach is necessary with several safe guards at various stages. Several suggestions have been made by the National Patient Safety Agency and have been endorsed by the various interested organisations: [1]. This advice has subsequently been replaced by more comprehensive application [2][3].

  • Confirm with patient prior to pre-medication (but beware patient with early dementia or confusion).
  • Indelible mark with arrow pointing at, or as near to site as possible
  • Operating surgeon should personally mark site. If delegated, the deputy should be present at surgery.
  • Relevant notes and imaging should be available and should follow patient to theatre.
  • Checks in ward, anaesthetic room and in theatre prior to commencement of surgery.
  • Teams should pause briefly prior to start of surgery to confirm correct patient, correct site and procedure to be performed.

Common pitfalls

  • Unexpected changes in operating theatre schedule.
  • Confused patient.
  • Mark not specific enough. For example, in toe amputation, mark should point to specific toe, not just the foot.
  • Proceeding to surgery without appropriate notes and radiology available.
  • Mark rubbed off during skin preparation or prior to surgery.
  • Duplicate mark produced accidentally because ink not dried and rubbed off onto opposite side.
  • Some surgeons mark an X on the side not for surgery - this can be confusing for obvious reasons.