Current practice on preoperative correct site surgical marking.
Abstract: Performing surgery at an incorrect site has devastating outcomes. The National Patient Safety agency and Royal College of Surgeons England have provided recommendations to promote correct site surgery with emphasis on surgical markings. There is little published data on surgical site marking practices amongst surgeons. A prospective audit on surgical site marking was performed on 500 surgical procedures: 204 inguinal hernias, 35 umbilical hernias, 48 varicose veins, 40 toenail removals, 123 excisions of skin lesions, 10 femoral artery procedures and 40 breast procedures. The results showed that 59% of markings were visible in theatre post sterile draping, 40.4% markings were not visible, and 0.6% (3/500) were not marked. Recommendations suggest the use of an arrow with an indelible marker pen. Our results show the use of an arrow in 64% of patients and this was the most common form of mark used. An appropriate marker pen was used on 88% of patients. There is no evident published data to compare our practice to that of other surgical units, however, to improve correct site surgery markings should be visible, recognisable and understood by all specialties and grades. A universal marking system to improve correct site surgery may be beneficial.
Subject: Preoperative care (Methods)
Preoperative care (Management)
Surgical errors (Prevention)
Authors: Masud, Dhalia
Moore, Alice
Massouh, Farouk
Pub Date: 06/01/2010
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: June, 2010 Source Volume: 20 Source Issue: 6
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 229896869
Full Text: Introduction

The consequences of performing surgery at an incorrect site can be devastating for all involved. Recurring news on wrong organs being removed and wrong site surgery (Dyer 2004, CHI 2000) shows evidence of completely avoidable mistakes. These include poor patient case note documentation and imaging checks against the patient in theatre and incorrect surgical markings (Dyer 2004, NPSA 2009). Correctly marking the site for surgery is crucial. Poor documentation and poor communication with the patient can lead to serious mistakes of wrong site surgery (CHI 2000).

The Joint Commission on Accreditation of Healthcare Organisation (JCAHO) in the United States of America has estimated the occurrence of reported wrong site surgery incidents as: 20% general surgery, 41% orthopaedic surgery, 14% neurosurgery, 11% urology and 14% maxillofacial, cardiovascular, ENT and ophthalmology cases (JCO 2001).

The National Patient Safety Agency (NPSA) was set up by the NHS in 2001 to tackle issues of adverse events in the NHS including those of wrong site surgery. The NPSA implemented the National Reporting and Learning system (NRLS), an incident reporting system for all members of the NHS. From 1 January 2007 to 31 December 2007 16 cases of wrong site surgery were reported with one severe outcome and one death. Five were cases of the wrong site being marked and eight were cases of the wrong side being prepared (NPSA 2009). The World Health Organisation (WHO) as part of the Safe Surgery Save Lives initiative has focused on implementing the WHO Safe Surgery Checklist (WHO 2008). This describes three phases of check during a procedure: before induction of anaesthesia ('sign in'), before the incision of the skin ('time out'), and before the patient leaves the operating room ('sign out'). The surgical site is checked in both the 'sign in' and 'time out' phases (WHO 2008, NPSA 2009).

The actual incidence of wrong site surgery is unknown (JCO 2001, Dunn 2006, Cullen et al 1995) because voluntary reporting is poor. Wald and Shojania (2001) compared voluntary reporting figures to the JCAHO with mandatory reporting figures to the New York Department of Health. This revealed that incidents may be underestimated by at least a factor of 20.

Giles et al (2006) showed most surgeons experience wrong site surgery. The Joint commission (JCO) (2001) reports risk factors for wrong site surgery (Table 1). These environments are experienced by all surgeons and so by definition all surgeons are at risk of being involved in wrong site surgery.

The NPSA (2005) advises the use of an indelible marker pen with an arrow extending to the site. This should remain visible post skin preparation and draping. Situations where marking may be inappropriate are teeth, mucous membranes, and bilateral simultaneous organ surgery e.g. tonsillectomy. In emergency cases surgery should not be delayed due to lack of marking. The operating surgeon or a nominated deputy who will be present in the operative theatre at the time of the procedure should mark the patient (NPSA 2005).

Although marking is an important process in promoting correct site surgery, little evidence is published on the marking practices. To improve correct site surgery marking, it is important to be aware of current practices and also to aim to devise a universal marking system recognised by all specialties and grades for commonly performed procedures.


Audit committee and surgical departmental approval was sought to carry out the audit. We performed a prospective audit of 500 surgical markings for elective procedures carried out by surgeons between June 2008 to May 2009. Visibility pre and post draping was noted. Also noted was whether an arrow was used to mark the surgical site, and the use of an indelible marker pen. This was tested using an alcohol skin prep wipe. An





Three procedures (0.6%), one inguinal hernia and two toenails were not marked prior to theatre.

Of the remaining 497, all were correct for location and laterality and were marked by an operating surgeon present in the surgical procedure i.e. the main surgeon or an assistant or an observing surgical member/trainee. Appropriate indelible marker pen was used for 88% (440/500) of cases, ballpoint pen for 2% (10/500) and non permanent marker pen (white board dry marker pens) for 9.4% (47/500). With regards to the type of marking, an arrow was used in 64% (320/500) of cases, and 11.8% (59/500) used crosses. In 23.6% (118/500) margins were marked, including all varicose veins. Figure 2 and Table 2 show how each different type of procedure was marked.

Of the 204 inguinal hernias 82.8% (169/204) were marked with an arrow and 12.3% (25/204) with a cross. Of umbilical hernias and varicose veins all 48 had the margins marked. From the 123 excision of lesions, 25.2% (31/123) had the margins marked, 67.5% (83/123) were marked with an arrow and 7.3% (9/123) were marked with a cross (Figure 2, Table 2).

Although 45/500 were marked, only 59% (295/500) of markings remained visible after draping (Figure 3, Table 3).

In 9% (45/500) of markings, non permanent marker was used and post cleaning and draping the marking was removed.

31.4% (157/500) of markings were placed where draping covered the markings (including permanent and non permanent markings) (Figure 4).

Figure 5 shows the proportions of each procedure where the marks remained visible. 56% (115/204) of the inguinal hernia markings were not visible after draping. All varicose veins and femoral artery aneurysms markings were visible after draping. Of the 40 breast markings, 20 markings were not visible after draping. All of these were marked in the clavicle region with an X.


Correct surgical marking is crucial in the preoperative management of a patient. Although our hospital has a good marking rate, the prospective audit has shown that only 59% of our total markings were visible post surgical draping. The remaining 40.4% that were marked could not be seen after draping, which defeats the purpose of marking. 0.6 % were not marked at all.

Visibility of marking post draping is imperative particularly when 'multiple surgeons' are involved. This has been shown to be a risk factor to wrong site surgery (JCO 2001). Preoperatively it is not uncommon for the patient to be marked by one surgeon, draped by the scrub nurse and the first incision made by another surgeon. If the side/site to be operated on is not obvious i.e. the mark is not visible (as in 41% of the cases in the audit) there is a risk for wrong site surgery.



The NPSA (2005) recommends the use of an arrow to mark the site of a surgical procedure. Our results showed that 64% (320/500) of cases were marked with an arrow, 11.8% (59/500) were marked with crosses, and in 21.8% (109/500) margins were marked.

It is clear in this audit that the blanket rule of marking with an arrow, as recommended, is not used by all our surgeons for all procedures. Results show that none of the varicose veins were marked with an arrow and the common practice of marking the outlines of the varicosities was sufficient to indicate which side was to be operated on (Figure 6).

86% (30/35) of umbilical hernias had the margins marked and 14% (5/35) were marked with an arrow. Umbilical hernias do not require marking (NPSA 2005). However, surgeons mark margins of the hernia to gauge its size.

The purpose of surgical site marking is to identify unambiguously the area of surgery (JCO 2004). 11.8 % of cases were marked with an 'X'. Marking with letters has been shown to be subject to interpretation and can cause confusion about the site of surgery (Johnstone 2007). Correct surgical marking should be a common language understood by all specialties. A surgeon marking with an X may mean the lesion is near the marking however, to a radiologist, an X is the exact spot for intervention. For this reason an arrow should be used where possible unless the procedure margins are marked preoperatively.


Of the 40 breast markings 20 were not visible post draping and all these were marked with an X in the clavicle region. It is likely that these were marked in the site for convenience to both the patient and surgeon and also to help maintain dignity. However as marks were not visible post draping this increased the risk for wrong site surgery. For mastectomy markings it was found that an arrow extending from the clavicle to the incision point was most convenient (Figure 7). The mark extending from the clavicle ensures that this is obvious enough for the patient to find and for healthcare professionals to check without repeated exposure of the breast, thus maintaining patients' dignity.

In 11.4 % of cases inappropriate marker pen was used (2% ballpoint pen, 9.4% non permanent marker). The type of marker pen can again increase wrong site surgery. Even when the surgeon marks the correct site in the correct manner, this can be easily removed with patient's normal activities and then with the cleaning solution on draping. Use of a ballpoint marker can be painful for the patient and less visible than an arrow marked with a permanent marker pen. A soft tipped marker pen that is quicker to apply and pain free is recommended.

The surgeon must also be aware that markings may imprint on extremities as one part of the body presses on another. This is demonstrated in marking for varicose veins on the medial aspect of the thigh, giving the appearance that both sides require procedures (Figure 6). This could also happen in the medial aspect of the arm, groin and trunk.

Inguinal hernias were the most common procedure (204/500) in this study and had the lowest visibility post draping. 56% (115/204) (see Table 3) of the markings for inguinal hernias were not visible post draping. It was found that the most simple and practical method for marking the inguinal hernia was an arrow in the lower quadrant pointing towards the groin.

It is not uncommon for an elective theatre list order to change on the day of surgery. Patients are cancelled, new patients are added. Surgeons change in the middle of the list. Therefore it is imperative that surgical marking is correct and clear. However, it is important to be aware that marking is only one of the steps involved in correct site surgery. Checking documentation, appropriate scans and checking the patient before and after the general anaesthesia is crucial, as recommended by the WHO (2008) NPSA (2009) and the JCAHO (2003). The WHO Surgical Safety Checklist (NPSA 2009) is an added measure to ensure that all members of the theatre staff are in agreement with the checks in a more formal dedicated manner.

Promoting correct site surgery involves clear surgical markings of a patient's skin prior to a surgical procedure. This study revealed the practices of surgical marking at one NHS teaching trust.

The findings were that all markings were correct for location and laterality. 59% of markings were carried out correctly, including being visible post draping. The remaining 41% of patient markings could not be seen when covered with drapes, the markings were removed as a non permanent marker had been used, or the patient was not marked at all. Visibility of marking is imperative post draping particularly with involvement of multiple surgeons and when the initial operating surgeon has not marked the patient. Inappropriate marker pens were used for 11.4% (57/500) of markings (ballpoint pens, non permanent marker pens).

The NPSA recommends use of an arrow to mark the operative site. This was followed in 64% of cases. In 11.8% (59/500) of cases crosses were used and 21.8% (109/500) margins were marked (includes all varicose veins).

The results of this audit demonstrate that, although surgical site marking was carried out in most cases 497/500, in a significant number marking was inadequate--defeating the purpose of marking. There was limited published data available for the results to be compared. It is clear that there is still some work to be done to improve the marking technique in the trust and the introduction of a universal marking system may be beneficial. It is recommended to use indelible marker pen with arrow extending to the site. This should remain visible post skin preparation and draping (NPSA 2005).

Correct clear marking is only one of the steps in promoting correct site surgery. Checking the patient's documentation and scans systematically is also recommended and the WHO Surgical Safety Checklist (NPSA 2009) is an added measure to ensure that all checks are completed as routine.


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Dhalia Masud


Plastics Registrar, Frimley Park Hospital, Camberley

Alice Moore

BM, BS, B Med Sci

FY1--Surgical House Officer, Frimley Park Hospital, Camberley

Farouk Massouh


Consultant Surgeon, Frimley Park Hospital, Camberley

No competing interests declared

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Correspondence address: Dhalia Masud, Frimley Park Hospital, Camberley, GU16 7UJ. Email:
Table 1 Risk factors for wrong site surgery

Emergency Surgery                    19%
Time pressure                        13%
Unusual Equipment/ Theatre Set up    13%
Multiple Surgeons                    13%
Multiple Procedures                  10%
Unusual Physical Characteristics     6%
Reprinted from JCO 2001

Table 2 Marking types of different procedures

                   Arrow   Crosses   Margins     No      TOTAL
                                     marked    marking

Inguinal hernia     169      25         9         1       204
Umbilical hernia     5        0        30         0       35
Varicose veins       0        0        48         0       48
Toenails            33        5         0         2       40
Excision of
  skin lesions      83        9        31         0       123
Breast              20       20         0         0       40
Femoral artery
  aneurysm          10        0         0         0       10
TOTAL               320      59        118        3       500

Table 3 Visibility of markings post draping

                             VISIBLE     NOT

Inguinal hernia                89        115     204
Umbilical hernia               25        10      35
Varicose veins                 48         0      48
Toenails                       10        30      40
Excision of lesions            93        30      123
Breast                         20        20      40
Femoral artery aneurysm        10         0      10

Figure 1 Preoperative marking audit proforma

Pre-operative marking audit Proforma

(100 patients June 08)

Grade of marker Consultant

Registrar SHO

1. Indelible marker used                          Yes       No

2. Arrow used If not what else                    Yes       No

3. Extends to/near to the incision site           Yes       No

If not where to

4. Remains visible after application of drapes    Yes       No

5. Marking undertaken by operating surgeon/       Yes       No
   nominated deputy who will be present
   in operating theatre

6. The surgical site is correct for
   a.) Location                                   Yes       No
   b.) Laterality                                 Yes       No
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