Transfer of surgical site marking

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It is now universal practice to mark any surgical site that is sided. In the United Kingdom, the normal procedure is to use an indelible marker pen to draw an arrow to indicate the correct limb or digit. This intraoperative photograph⇑ shows the inadvertent transfer of wet ink from one site to another, owing to the patient crossing his legs. This patient’s left, apparently marked limb was uncovered in theatre, and was about to undergo wrong side surgery. The correct right side was identified when reviewing the final World Health Organization checklist for surgical safety. This incident demonstrates the real risk of transfer marking.