Abstract
Wrong-site surgery is a devastating complication, and its avoidance requires uncompromising vigilance. The Joint Commission on Accreditation of Healthcare Organizations has labeled wrong-site surgery as a sentinel event and requires marking the surgical site before initiating an operation. We present a case involving the duplication of a preprocedure mark. A complete review of the patient's medical record averted disaster, but the case emphasizes the need for constant attentiveness by all members of the procedural team.
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