Transfer of a pre-operative surgical site mark to the opposite side increases the risk of wrong site surgery.

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LETTERS AND COMMENTS
Ann R Coll Surg Engl 2009; 91: 443–445
444
almost guaranteed to get NSI.3We can no longer gamble
with our careers, our finance or our health by failing to
report needle-stick injury.
References
1. Kennedy R, Kelly S, Gonsalves S, McCann PA. Barriers to the reporting and
management of needle-stick injuries among surgeons. Presented at the Royal
College of Surgeons of Edinburgh Audit Symposium, Edinburgh, March 2007.
2. White SM. Needlestuck. Anaesthesia 2007; 62: 1199–201.
3. Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM et al.
Needle-stick injuries among surgeons in training. N Engl J Med 2007; 356:
2693–9.
AUTHOR’S RESPONSE
doi 10.1308/003588409X432266
WILLIAM THOMAS
Department of Trauma and Orthopaedics, Royal United Hospital,
Bath, UK
CORRESPONDENCE TO
William Thomas, Isther Cottage, Hampton Row, Bathwick,
Bath BA2 6QS, UK
E: williamthomas@doctors.org.uk
We would like to thank Stephen Kelly for his helpful com-
ments and were particularly pleased to see that our findings
from a single, busy district hospital are indeed reflected by
his own very similar study across the surgical specialties in
three quite diverse centres.1This certainly reinforces the
message that current practices are leaving surgeons
exposed; although transmission rates are currently small,
they are generally increasing. We agree that it is the on-the-
spot decision making undertaken by the operating surgeon
that is the most risk-prone event and are particularly inter-
ested in his efforts at reducing this. Management of these
incidents by independent occupational health staff should
be encouraged but the emphasis of their involvement must
be to make the process more straightforward, taking the
perceived inconvenience out of the process that deters so
many.2I would be interested to see if the structures put in
place by the Kelly and McCann group have made a differ-
ence in reducing the barriers to reporting in their hospitals.
We acknowledge that the testing of anaesthetised
patients for blood-borne viruses is an area of unresolved
ethical debate. In principle, we support the idea of patients
giving pre-operative consent to a blood test in the event of a
needle stick injury.
The ‘take-home’ message from both of these pieces of
work is that needle stick injuries are common in surgeons
and are associated with a small, but significant, risk to our
career, health, families and not least our patients.
Thankfully, to date, we have not seen a transmission of a
blood-borne virus to a surgeon but note that other theatre
staff have been inoculated. It is our responsibility as sur-
geons to protect our working environment by ensuring
structures are in place to allow the consistent, safe and
responsible management of these incidents.
References
1. Kennedy R, Kelly S, Gonsalves S, McCann PA. Barriers to the reporting and
management of needle-stick injuries among surgeons. Presented at the Royal
College of Surgeons of Edinburgh Audit Symposium, Edinburgh, March 2007.
2. Wallis GC, Kim WY, Chaudhary BR, Henderson JJ. Perceptions of orthopaedic
surgeons regarding hepatitis C viral transmission: a questionnaire survey. Ann R
Coll Surg Engl 2007; 89: 276–80.
LETTER
doi 10.1308/003588409X432275
Transfer of a pre-operative surgical site mark to
the opposite side increases the risk of wrong site
surgery
PM ROBINSON1, LTSW MUIR2
1Department of Orthopaedics, Trafford General Hospital,
Manchester, UK
2Department of Orthopaedics, Salford Royal Hospital NHS
Foundation Trust, Salford, UK
CORRESPONDENCE TO
Paul Robinson, 176B Stannington View Road, Crookes, Sheffield
S10 1SS,UK
E: paulrobinson230979@yahoo.co.uk
Surgery performed at the incorrect anatomical site can be
devastating for both patients and surgeons.1We wish to
highlight the case of a patient who had been correctly
Figure 1 Left forearm correctly marked with an arrow.

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LETTERS AND COMMENTS
Ann R Coll Surg Engl 2009; 91: 443–445
445
marked for surgery on the left hand with an arrow on the
left forearm (Fig. 1: taken at the end of the procedure) who
was found to also have an erroneous arrow on the right
thumb (Fig. 2). On questioning the patient, it became clear
that the arrow had become imprinted on the thumb when
the patient had crossed his or her hands. Transfer of the
mark not only introduces an erroneous mark, but also fades
the correct mark.
The American Academy of Orthopedic Surgeons estimat-
ed that an orthopaedic surgeon has a 1 in 4 chance of per-
forming wrong-site surgery during a 35-year career.2
Although there are anecdotal stories of transferred site
marks we have identified only one previously published
instance.3This was in a patient whose mark was transferred
from the forehead onto the bar of a slit lamp and then onto
the brow of the next patient to use the lamp.
The use of marker pens does present a small risk in
these circumstances of which all users should be aware.
Guidelines on pre-operative marking have been produced
by The Royal College of Surgeons of England in conjunction
with the National Patient Safety Agency4and feature in the
World Health Organization’s Surgical safety checklist.5
References
1. Dyer C. Surgeons cleared of manslaughter after removing wrong kidney. BMJ
2002; 325: 9.
2. American Academy of Orthopedic Surgeons. Wrong Site Surgery.
<http://www5.aaos.org/wrong/viewscrp.cfm#Start0> [Accessed 22 March 2008].
3. Lambley RG, Herbert EN. Preoperative site marking for eye surgery may be
transferred from patient to patient or moved, increasing the potential for wrong
site surgery. Br J Ophthalmol 2008; 92: 295.
4. The Royal College of Surgeons of England and the National Patient Safety
Agency. Patient safety alert 06; Pre-operative marking recommendations.
<http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/correct-site-
surgery/>.
5. World Health Organization. Surgical safety checklist.
<http://www.who.int/patientsafety/safesurgery/ss_checklist/en/>.
Figure 2 Arrow transferred to right thumb.