Archive April 2018 XIX, No. 4

The Ink Must Go Where the Knife Will Cut

There'll be less wrong-site surgery if your surgeons cut through their initials.

Richard Abowitz


Initial Cut
INITIAL CUT The most important site marking tip: initial where you cut.

Cut through your initials. Initial where you cut. Sign your site. However you say it, the meaning is clear. Surgeons use an indelible skin marker to write the first letter of their first and last name on the surgical site, and then make an incision through the ink, as if it were a bull's eye. If every surgeon would do that one simple thing every time, the safety experts say there'd be a lot fewer wrong-site surgeries.

WASH AWAY? Use an indelible marker to mark the site to ensure that the pre-op skin prep solution doesn't wash away the mark.

Sounds simple, right? But every year, U.S. surgeons perform about 2,000 incorrect operations. Perhaps the best known case is one you've probably heard before. Hand and arm surgeon David Ring, MD, PhD, performed a carpal tunnel release instead of a trigger finger release on a 65-year-old female patient.

Dr. Ring famously broke the silence that surrounds surgeon errors when he issued a public mea culpa in the Nov. 11, 2010, edition of the New England Journal of Medicine (, sharing in great detail with his fellow docs the missteps that led to his error. Dr. Ring has since lectured and written about wrong-site surgery countless times, along the way becoming, as he puts it, "the poster child for operating on the wrong body part."

Dr. Ring was a proponent of the "sign your site" protocol before his wrong-site error. But hospital policy was for a nurse or a surgeon to mark the limb, not the site. In Dr. Ring's wrong-site case, a nurse had marked the correct arm at the wrist, but not the planned incision site on the hand.

Dr. Ring gives credence to using checklists and hard-stop time outs. He also has a few rules on site-marking:

  • The surgeon must make the mark, but only after confirming the indication (appropriateness), affirming the patient's desire for surgery (consent), and verifying the site and the surgery with the patient and on the consent form.
  • The ink must go where the knife will cut. It should be a bull's-eye that draws the attention of the surgeon and team to the correct side, site and surgery. It cannot go nearby on the limb.
  • If there is not ink where the consent and the team say the cut should be made, the surgery should not proceed.
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