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Background
Since 2001 the National Patient Safety Agency (NPSA) has reported 59 cases of patient safety incidents relating to incorrect patient site or procedures. 1 The results of these errors can be devastating for the patient and staff and have major clinical, psychological and legal repercussions. Subsequently the NPSA in association with the Royal College of Surgeons (RCS) have developed recommendations for preoperative marking (including who, when, and where to mark). This has been further endorsed by the Joint Commission on Accreditation of Healthcare Organisations (JCHO) 2 and the American College of Surgeons. 3 This has now been carried forward to become one of the core safety checks in the World Health Organization Surgical Safety Checklist. 4
We present an unusual case where despite the implementation of a preoperative marking protocol there was still confusion as to the surgical site for the procedure. We aim to highlight this specific problem and hope to use this as an example to all involved with preoperative marking, thus avoiding future mistakes.
Case presentation
A 65-year-old man sustained a right displaced ankle fracture. He was subsequently admitted to the acute trauma ward and underwent routine...