SRG-SOP-002: Surgical site marking and patient identification before every operation

Standard operating procedure (SOP) · SRG-SOP-002 · Version 0.1 · Draft for local review

Supports: 60.2

1. Purpose

To make sure the correct patient has the correct procedure on the correct site, by marking the site before the patient goes to theatre and by checking the mark and the identity at the sign-in and time-out pauses (60.2).

2. Scope

Item	Coverage
Applies to	Surgeons, anaesthetists, operating department practitioners, nurses and any team member who takes part in the sign-in or time-out
Procedures	All operations and invasive procedures in theatre, endoscopy suites and procedure rooms, including day surgery
Sites that need marking	Any procedure with a left or right side, a digit, a finger or toe, a spinal level or any other site where a wrong-site error is possible

3. Definitions

Term	Meaning in this SOP
Site mark	A clear, permanent, non-erasable mark placed on the skin at the operative site by the operating surgeon, using a pen approved for the purpose
Sign-in	The first pause of the WHO Surgical Safety Checklist, before anaesthesia
Time-out	The second pause, before the first incision, where the team confirms identity, procedure and site
Site confirmation	The check that the site mark matches the consent, the booking and the imaging

4. Background

Wrong-site surgery is rare but preventable, and most cases happen when the site is not confirmed independently by the team. Marking the site before the patient is sedated, and checking the mark at two pauses, reduces the risk of error. The marking and the checks are not a replacement for the surgeon's own confirmation of the site.

5. Responsibilities

Role	Responsibility
Operating surgeon	Marks the site, confirms the site with the patient, and states the procedure and site at time-out
Anaesthetist	Confirms identity and consent at sign-in, and checks the mark is visible before anaesthesia
Operating department practitioner or nurse	Checks the mark, the consent and the booking, and leads the checklist
Service manager	Keeps the procedure, the pen stock and the audit in place

6. Procedure

6.1 Before the patient goes to theatre

1. Confirm the procedure and the site with the patient, using the consent form and the booking.
2. Check the imaging, where relevant, and confirm the site on the image.
3. The operating surgeon marks the site while the patient is awake, with the patient's participation where possible.
4. Use a mark that does not wash off during preparation. Do not mark the site that is not to be operated on.
5. Record on the checklist that the site has been marked, or that the site is not applicable, with the reason.

6.2 Sign-in

1. Confirm the patient's identity with two identifiers, such as name and date of birth, against the wristband and the booking.
2. Confirm the procedure and the consent form.
3. Confirm the site mark is present and visible, or that marking is not applicable.
4. Stop the procedure if any of these is unclear.

6.3 Time-out

1. Before the first incision, the team stops and states the patient's name, the procedure and the site.
2. The surgeon confirms the site from the mark and the imaging, and each team member confirms in turn.
3. Any team member may raise a concern, which must be resolved before the incision.

7. Decision points

Situation	Action
Mark missing or unclear	Stop. Mark the site now with the surgeon, and repeat the sign-in and time-out
Patient cannot confirm the site	Confirm the site with the consent and imaging, with a second clinician, and record the decision
Site on the imaging differs from the consent	Stop and discuss with the surgeon and the consultant before any incision
Emergency procedure where marking is not possible	Record the reason, and confirm the site with the team and the imaging before the incision

8. Escalation

• Wrong-site or wrong-patient event, or a near miss: stop the procedure if it has not started, report under INC-SOP-001 within 24 hours, and inform the medical director the same day.
• Repeated missing marks for one surgeon or team: the service manager reviews practice the same month.

9. Monitoring

The service manager audits 30 operations each month for site marking and the checks at sign-in and time-out, and reports results to the surgical governance meeting each quarter.

Measure	Target
Procedures where marking was required and was done	100 percent
Sign-in and time-out completed and recorded	100 percent
Wrong-site or wrong-patient events	0
Near misses reported	Recorded, and reviewed every quarter

10. Records

• Surgical safety checklist record (SRG-FRM-001), with the sign-in and time-out.
• Patient identification check log (ID-FRM-001).
• Incident reports.

11. Training

All surgeons, anaesthetists and theatre staff complete training on site marking and the checklist at induction and every year, with a practical assessment in a simulated theatre.

12. Related documents

Code	Document
SRG-SOP-001	Surgical safety checklist procedure
SRG-POL-001	Surgical safety checklist and team pause
SRG-FRM-001	Surgical safety checklist record
ID-FRM-001	Patient identification check log
INC-SOP-001	Root cause analysis of serious incidents

13. Evidence

This SOP is based on the reference sources listed below and on the requirement of criterion 60.2 of the ASF standards. The marking rules must be checked against the facility's surgical policy and the WHO checklist at each review.

E-learning for this document

• No course linked yet. Request a surgical safety course from the academy (see the Standard 60 request list).

References

1. World Health Organization. Surgical Safety Checklist (first edition) and its implementation guidance. Current edition.
2. The Joint Commission. National Patient Safety Goal NPSG.01.01.01 on patient identification, and NPSG.04.01.01 on the correct site, procedure and patient. Current edition.
3. Facility surgical policy and marking pen specification (to be inserted by the facility at adoption).

Change history

Version	Date	Change
0.1	2026-10-26	First draft for review. Not yet approved by the ASF Expert Committee.