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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 12/16/2019 12:00:00 AM
Country: South Korea

This alert describes patient safety incidents of surgery being performed on the wrong body part. Contributing factors were wrong surgical site marking, wrong check of the examination image (X-ray), and removal of a surgical marker before the procedure. Two cases are described. Recommendations focusing on surgical site marking and use of time out procedures are provided. Included in the alert are an example of an operating room performing a time out and guidelines for marking surgical sites.

Additional Details

Device:
indelible pen, bracelet, wrist band


Wrong surgery because of a wrong surgical site marking