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How Marking The Site On The Patient Using An Ink Marker May Prevent Wrong-Site Surgery

Often referred to as “never events”, horrifying medical errors include when surgery is conducted on the wrong body part, an incorrect procedure is performed, or surgery is conducted on the wrong patient. These negligence acts have life-altering consequences. It is estimated that several thousand of these surgical errors occur annually in the U.S. The majority of wrong-site surgeries involve a medical procedure that is performed on the correct body part; however, on the wrong side of the patient’s body.

Marking the surgical site is an effective measure. The surgeon uses an indelible skin marker to place their initials on the site where the incision will occur. This marking is to be conducted after the patient confirms the procedure, provides consent for the procedure, and the consent form is completed. Any discrepancies between the consent form and the ink is a “red flag” to halt the procedure.

Some notable examples of wrong-site surgery are:

  • Dr. David Ring performed a carpal tunnel release procedure on a 65-year-old woman who was supposed to have a trigger finger release. A nurse had marked the correct arm but at the wrong site. Since the incident, Ring has been an advocate for the prevention of wrong site surgery.
  • In Las Vegas, a 54-year-old man awoke after surgery and noticed they had operated on the wrong knee. The surgeon admitted the error and performed the procedure on the other knee. The man was charged for both procedures.
  • A woman, age 43, acquired a dangerous infection that required a leg amputation. Following the procedure, she suspected a problem. The surgeon had removed the wrong leg.

Hospitals in Pursuit of Excellence reported four primary causes for these errors, which included mistakes in scheduling, pre-operation, in the operating room, and organizational failure. Errors in the pre-operation phase included failing to consistently mark the surgical site and using the incorrect type of markers. This problem required new procedures including using a special marker to write the surgeon’s initials as close to the point of the incision as possible. In the operating room, often the marks are removed amid preparation; this problem was solved by requiring that only indelible markers be used.

A Committee on Perioperative Care with the American College of Surgeons published some best practices for preventing wrong site surgery. They emphasized the importance of first verifying the identity of the patient. Next, the operating room schedule should be confirmed for performing the proper procedure. The patient, or their representative, should also confirm the nature of the procedure. The surgeon should always mark the point of incision prior to any anesthesia is introduced.

Organizations must put in place procedures that are done consistently to prevent critical mistakes such a wrong site surgery. This problem is more than simply a surgical issue and must be emphasized among administrators and management. It must begin during the intake or scheduling process and procedural adherence should continue on into the operating room.

About the Author

Briggs Bedigian
Briggs Bedigian

H. Briggs Bedigian (“Briggs”) is a founding partner of Gilman & Bedigian, LLC.  Prior to forming Gilman & Bedigian, LLC, Briggs was a partner at Wais, Vogelstein and Bedigian, LLC, where he was the head of the firm’s litigation practice.  Briggs’ legal practice is focused on representing clients involved in medical malpractice and catastrophic personal injury cases. 


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