title: Does the type of skin marker prevent marking erasure of surgical-site markings?
abstract: OBJECTIVE
  Site marking is essential to prevent wrong-site surgery, and there are many skin markers commercially available. However, preoperative skin preparation can erase the site mark, especially when a chlorhexidine skin preparation solution that requires skin scrubbing is used. The purpose of our study was to test the hypothesis that some markers can withstand skin preparation with a chlorhexidine-based skin preparation solution in a manner similar to that of an iodine-based solution.
  
  
  METHODS
  On each of 5 cadaveric skin flaps, we made 2 rows of site markings with 9 types of markers. We then subjected one row of markings on each flap to a chlorhexidine-based solution and the other row to an iodine-based solution. A digital photograph was taken before and after each skin preparation. Using imaging software, the contrast in grayscale between the skin and skin marking was measured on each photograph. The effect of the type of marker and skin preparation solution on the difference in grayscale contrast was evaluated by multiple linear regression analysis and significant differences were determined (P < .05).
  
  
  RESULTS
  In all cases, the chlorhexidine-based skin preparation solution significantly decreased the contrast measured. No marker was significantly better than another.
  
  
  CONCLUSIONS
  We conclude that all 9 skin markers are significantly erased with the chlorhexidine-based skin preparation solution. The development of a better skin marker or a chlorhexidine-based skin preparation solution that does not erase site markings is essential to prevent wrong-site surgeries and promote patient safety.
authors.affiliation: International Center for Orthopaedic Advancement, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
authors.forename: Simon C
authors.initials: SC
authors.lastname: Mears
authors.forename: Arman B
authors.initials: AB
authors.lastname: Davani
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Belkoff