Pa Patient Saf Advis 2018 Sep;15(3).
Safety Stories: Site Marks
Obstetrics and Gynecology, Ophthalmology, Orthopedics, Otolaryngology, Surgery, Urology
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This vignette presents a brief, timely highlight of surgical site marking events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.

Site Marks


The physician assistant began to prep the patient for surgery. The surgeon observed through the OR [operating room] window that the site mark was not visible. The surgeon entered the OR and confirmed that the prep had been initiated on the wrong extremity. The correct site was verified. The prep, draping, time-out and procedure were completed on the correct extremity.

Operating room staff noticed that the patient's surgical site mark was on a dressing and not the patient's skin. When requested to mark the site, the surgeon berated the staff in front of the patient. The surgeon continued to make sarcastic remarks about site marking throughout the course of the procedure.

Surgeon marked the patient's arm instead of her shoulder, and the nurse requested that he re-mark the patient. When the patient arrived in the OR, she had multiple large marks covering her extremity. During the time-out, the surgeon asked if the site marking was sufficient.


OR procedures involve a cascade of choreographed events, and finely honed teams accomplish complex tasks following both implicit and explicit signals. Site marks provide a very direct signal that supports procedure verification before irreversible actions—such as incisions—occur. Site marks provide information not just for the surgeon or anesthesiologist (e.g., for a nerve block), but for the entire team, which is coordinating the equipment, supplies, and room set-up.

In the first event described above, the site mark provided important information to the surgeon, who is to be commended for alertness in recognizing the hazard even before entering the OR. Unfortunately, in the second and third events, the surgeons demonstrated disrespect by their actions and by their words; this disrespect is likely to impair team function throughout the course of the procedure.1

Wrong-site perioperative procedures continue to occur about once a week in Pennsylvania,2 and any member of the team might be the individual who recognizes and prevents a wrong-site procedure. The Authority offers a gap analysis tool for OR personnel3 and a poster for patients and their families.4

Respectful teamwork helps all team members contribute to decreasing the incidence of these unwanted events.

* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.


  1. Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskin KS, Bamberger PA. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015 Sep;136(3):487-95. Also available: PMID: 26260718
  2. Arnold TV. Update on wrong-site surgery: more data provides more insight. Pa Patient Saf Advis. 2018 Mar;15(1).
  3. Pennsylvania Patient Safety Authority. Gap analysis and action plan to prevent wrong-site surgery. Harrisburg (PA): Pennsylvania Patient Safety Authority; 2015, updated 2017 Oct 13. 4 p. Also available:   
  4. Pennsylvania Patient Safety Authority. Patients and surgical teams work together to avoid wrong site surgery. Harrisburg (PA): Pennsylvania Patient Safety Authority; 1 p. Also available:  

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