title: Duplication of surgical site marking.
abstract: 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.
authors.affiliation: DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. jdavis7@med.miami.edu
authors.forename: James S
authors.initials: JS
authors.lastname: Davis
authors.forename: Jagajan
authors.initials: J
authors.lastname: Karmacharya
authors.forename: Carl I
authors.initials: CI
authors.lastname: Schulman
mesh_terms: D001741:Black or African American; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D017751:Safety Management / Q000379:methods*; D013514:Surgical Procedures, Operative / Q000379:methods*