It was another busy Monday morning. It was a whole day theatre day and my boss and I had been going round to see all the patients beforehand.
The last patient we saw was a woman who was due to have an operation on her Achilles tendon. She turned round and lay prone as we examined her. Then we put a big black arrow on her calf.
After that, we returned to theatre and began operating. It is our practice to recheck every patient routinely before they are anaesthetised.
After finishing the second case, we went to the anaesthetic room to check our next patient, who was the woman with the tendon problem. We noticed that she had an arrow on the front of her right leg, although she was due to have an operation on the left one. We were embarrassed and did not know what to say. But then we realised that she also had an arrow on her left calf.
For a few minutes we did not realise what had happened. Then it occurred to us that after we had put the arrow on her left calf, she had crossed her left leg over the right one and had made an impression of this arrow on the front of her right leg. Hence the arrow on both legs.
Finally, the confusion was resolved and we operated on the correct leg. We learnt an important lesson—that one should always mark the operation site in a way that is not going to lead to ambiguity.
Footnotes
We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to.