Difficult Procedural and Surgical Site Marking

Preventing mistakes in surgery, including operating on the patient’s wrong site, is one of the Joint Commission’s 2025 National Patient Safety Goals. Publicly available resources through its Speak Up campaign encourage patients and their families to be involved members of the care team and advocate to ensure the correct surgical site has been marked.^1,2

When the site is difficult or impossible to mark due to location or skin concerns, the patient’s risk for wrong-site surgeries increases. This can occur in many settings, even during less invasive bedside procedures, and is common in cases involving teeth, the perineum, mucosal surfaces, multiple digits, casted limbs, internal organs, or lateralized organs such as ureters. Because the procedural environment is complex, there is often a disconnect between how work is imagined versus how work is done. Adherence to a robust policy outlining best practices when difficult site marking is essential to mitigate risks.

Risk of harm

Procedures performed on the wrong site can result in significant patient harm, as well as the need for additional procedures, prolonged exposure to anesthesia, increased length of hospital stay, and delayed treatment of the actual condition. Additional harm may include psychological trauma, loss of trust in the health care system, potential long-term disability, and increased risk of infection or complications.³

From an institutional perspective, wrong-site procedures can also lead to legal action, regulatory penalties, reputational damage, and increased health care costs.

Pediatric considerations

In pediatric patients, site marking must be adapted to developmental, emotional, and physical needs. Key things to consider:

• Surgical site skin marking may not be feasible on pre-term infants due to skin frailty and the increased risk for permanent staining or dermatitis with ink absorption.
• Sensory-sensitive or neurodivergent populations may perceive marking as distressing or even traumatic.
• Adolescents may experience discomfort, embarrassment, or distress when marking involves sensitive/private areas, making direct marking inappropriate or impractical due to modesty or anatomical constraints.

Recommended actions

• Identify all procedures involving sites that are technically anatomically impossible or impractical to mark and the settings where they may occur (e.g., bedside, emergency department, ambulatory care, operating room).
• Develop a policy (example) that clearly addresses best practices and protocols for all situations, including when alternative site marking processes are required. The policy should dictate:
• Who can complete the site marking process.
• When to complete the marking process.
• How to complete the site marking, in detail:
• The marking should be as close to the surgical site as reasonably possible.
• For patients having two or more procedures, consider marking the site with the proceduralist’s initials along with the number that correlates with the procedures on the consent. For example, the first procedure listed on the consent will correlate to the procedure listed first on the OR schedule and will be marked on the patient as “[proceduralist’s initials] 1.”
• Make standard anatomical diagrams available for alternative marking forms (example).
• What additional identifiers or processes may be needed when using alternative site marking methods (e.g., special arm band or hospital gown).
• Where procedures with difficult to mark sites can be completed (e.g., bedside may be exempt).
• Process for procedures listed as “possible.”
• Standardize the process to ensure compliance from the entire surgical team throughout the procedure(s).
• No matter what method is used (e.g. skin, alternative marking form), confirm that the surgical site marking remains visible after draping or repositioning and is always accessible to the entire procedural team.
• Ensure the use of timeouts throughout the procedure(s). Considerations include:
• First timeout (immediate pre-operative verification): Use to identify correct patient, procedure (visual inspection of operative consent), and site (visual inspection of the site marking) with the anesthesia provider, circulating RN, and patient and family.
• Second timeout: Use to identify correct patient, proceduralist, operative site(s), anticipated risks, and special equipment, including implants prior to incision. Consider bringing up radiographs or other imaging to confirm laterality. When an alternative marking form is used, this time-out becomes the critical final safety check, and post-induction marking can sometimes be done if needed and appropriate.
• Additional timeout(s): Use for patients having two or more procedures, procedures on multiple sites, or if the proceduralist changes.
• Final timeout (case debriefing at the conclusion of the procedure): Use to communicate key issues such as verified counts, specimen labeling, and potential recovery concerns.
• Safety note: Using an alternative form does not replace surgical site verification. It reinforces the need for heightened awareness and strict adherence to the Universal Protocol.
• Create an organizational culture that supports family and patient involvement in the marking process.
• Conduct an assessment, such as a GEMBA walk, to validate actual practice compared with written policies and procedures in applicable settings.
• Establish simulated training activities for alternative site marking surgeries and procedures.
• Develop job aides and real-time reminders for caregivers when sites are anatomically impossible or impractical to mark, or when the patient or family refuses marking. Consider utilizing Child Life services.

Target audiences

Operating room leaders, surgical staff, nursing staff, ambulatory care, clinical educators, emergency/urgent care, medical leaders, nursing leaders, outpatient surgery, quality and safety leaders, specialty care services, vascular access teams.

What can I do with this alert?

• Forward to the recommended target audiences for evaluation.
• Include in your daily safety brief.
• Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm.
• Let us know what is working and what additional information you need.

Supporting resources

• AORN Guidelines and Resources
• Children’s Nebraska’s Surgical Site Marking Policy
• Children’s Nebraska’s Alternative Site Marking Form
• PSO Safety Watch: Wrong-site Frenulum Procedural Interventions

References

• The Joint Commission. (2020). Speak Up™ campaigns. Speak Up For Safe Surgery.
• The Joint Commission. (2025). Hospital: 2025 National Patient Safety Goal Standard UP.01.01.01-UP.01.03.01, p. 14-17.
• Zil-E-Ali, A., Laubscher, L., Kourampi, I., & Tsagkaris C. (2023). Is surgery on the right track? The burden of wrong-site surgery. Baylor University Medical Center Proceedings, 36(5), 657-660. doi:10.1080/08998280.2023.2231714.
• Zanatta, D. A., Carvalho, V. O., & da Silva, R. P. G. V. C. (2023). What the skin of 341 premature newborns says - a transversal study. J Pediatr, 99(6), 582-587. doi:10.1016/j.jped.2023.04.005.