Duplication of surgical site marking

James S. Davis, Jagajan Karmacharya, Carl I. Schulman

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Wrong-site surgery is a devastating complication, and its avoidance requires uncompromising vigilance. The Joint Commission on Accreditation of Healthcare Organizations has labeled wrong-site surgery as a sentinel event and requires marking the surgical site before initiating an operation. We present a case involving the duplication of a preprocedure mark. A complete review of the patient's medical record averted disaster, but the case emphasizes the need for constant attentiveness by all members of the procedural team.

Original languageEnglish (US)
Pages (from-to)151-152
Number of pages2
JournalJournal of Patient Safety
Issue number4
StatePublished - Dec 1 2012


  • complications
  • surgery
  • surgical marking
  • wrong-site surgery

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health


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