BMJ Case Reports 2018; doi:10.1136/bcr-2017-223704
  • Images in…

Risk of operating on the wrong site: how to avoid a never event

  1. Robin Kanagasabay
  1. Department of Cardiothoracic Surgery, St George’s Hospital, London, UK
  1. Correspondence to Joy C Edlin, joy.edlin{at}
  • Accepted 27 March 2018
  • Published 7 May 2018


A 23-year-old man was referred to our unit for surgery for a right-sided recurrent primary spontaneous pneumothorax. On the eve of his surgery, he was consented and marked for the procedure. On examination of the patient, a play symbol tattoo was noted on the left side of the patient’s torso and pointing towards the patient’s left side, with the potential to cause confusion of the site of surgery. A black arrow in indelible ink was drawn on the patient’s right shoulder to indicate the correct site for surgery (figure 1).

Figure 1

Which is the correct surgical site? Photograph of male …

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