Risk of operating on the wrong site: how to avoid a never event

Description

A 23-year-old man was referred to our unit for surgery for a right-sided recurrent primary spontaneous pneumothorax. On the eve of his surgery, he was consented and marked for the procedure. On examination of the patient, a play symbol tattoo was noted on the left side of the patient's torso and pointing towards the patient's left side, with the potential to cause confusion of the site of surgery. A black arrow in indelible ink was drawn on the patient's right shoulder to indicate the correct site for surgery (figure 1).

Figure 1

Which is the correct surgical site? Photograph of male torso showing a surgical site marking on the patient's right shoulder and a play symbol tattoo, pointing towards the patient's left side, on the left side of the thorax.

The first item on the National Patient Safety Agency's...

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