Article Text

Learning from errors
Preoperative surgical marking: a case of seeing double
  1. Milap Rughani1,
  2. Michail Kokkinakis2,
  3. Marc Davison3
  1. 1John Radcliffe Hospital, Plastic Surgery, Headington, Oxford OX3 9DU, UK
  2. 2Buckinghamshire Hospitals NHS Trust, Trauma and Orthopaedics, Mandeville Road, Aylesbury HP21 8AL, UK
  3. 3Buckinghamshire Hospitals NHS Trust, Department of Anaesthetics, Mandeville Road, Aylesbury HP21 8AL, UK
  1. Correspondence to Milap Rughani, mrughani{at}


Preoperative marking is an integral part of the care of patients undergoing surgical procedures. It occurs on a daily basis in hospitals and involves all members of the healthcare staff and the patient. Incorrect marking or errors can lead to devastating consequences for the patient and staff involved. We present an unusual case of seeing double arrows on a patient undergoing emergency orthopaedic surgery, despite standard preoperative marking procedures. This was recognised in the anaesthetic room and the correct site was confirmed. We aim to highlight this specific problem and remind all involved in preoperative marking of the dangers of a mirror imprint, thereby avoiding seeing double in the anaesthetic or operating room.

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  • Competing interests: None.

  • Patient consent: Patient/guardian consent was obtained for publication.

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