What is marking in surgery? Understanding this vital safety procedure

September 28, 2025 •

3 min read

According to the Joint Commission, marking the surgical site is a key component of the Universal Protocol for preventing wrong-site surgery. So, what is marking in surgery? It is a mandatory pre-operative procedure where the correct anatomical location is clearly and unambiguously identified to ensure patient safety and procedure accuracy.

Quick Summary

Marking in surgery is the process of using indelible ink to clearly mark the intended surgical site on a patient's body, confirming laterality and location to prevent wrong-site errors. This critical safety protocol involves the surgeon and the patient, ensuring all members of the surgical team are aligned before an operation begins.

Key Points

Mandatory Safety Protocol: Surgical marking is a mandatory pre-operative procedure to confirm the correct surgical location.
Prevents "Never Events": The primary goal is to prevent wrong-site, wrong-procedure, or wrong-person surgery, also known as "never events."
Integral to the Universal Protocol: Marking is a critical step in The Joint Commission's Universal Protocol, along with pre-procedure verification and the 'time out.'
Patient Participation is Key: The surgeon marks the site with the patient's involvement to ensure confirmation and consent.
Clear and Unambiguous: The mark must be visible after prepping and draping and should be clear to avoid any misinterpretation.
More Than Just Skin Deep: Marking can also be done on internal tissues using dyes or sutures and confirmed with imaging.
Robust System: It's a key part of a multi-layered safety system that includes checklists, training, and open communication.

The Core Purpose of Surgical Marking

Surgical marking is a fundamental patient safety measure designed to prevent "never events" like wrong-site, wrong-procedure, or wrong-person surgery. It acts as a visual and verbal checkpoint, enhancing communication among the surgical team. The Universal Protocol by The Joint Commission mandates this for procedures involving laterality, multiple structures, or levels. Marking creates a clear reference point to reduce risks from miscommunication or distractions.

The Universal Protocol: A Standardized Safety Process

Surgical site marking is a critical step in The Universal Protocol, a three-step process to prevent surgical errors:

Pre-procedure Verification: Confirming the correct patient, site, and procedure by reviewing documents like consent forms and imaging.
Surgical Site Marking: Applying a clear mark on the skin at or near the incision site, visible after prepping and draping. The patient should participate when possible.
"Time Out": A final check by the entire surgical team before the procedure to confirm patient identity, procedure, and marked site.

How Surgical Marking Works in Practice

The operating surgeon typically performs the marking, often with the patient involved. This confirms the location and involves the patient in their care. The mark, usually initials or a line, is made with sterile, non-toxic ink resistant to skin preparation. The mark's appearance and location vary based on the procedure, such as marking a limb for orthopedic surgery or drawing guidelines for cosmetic procedures.

Types of Surgical Marking

Surgical marking extends beyond skin marking. Various methods ensure precision depending on the procedure. Here's a comparison:


Feature	Skin Marking	Internal Tissue Marking	Specimen Marking	Imaging-Guided Marking
Purpose	Identify incision site, laterality, or level on the body surface.	Delineate structures, vessels, or nerves within the body.	Indicate borders or orientation of excised tissue for pathology.	Pinpoint exact location for procedures like biopsies or spine surgery.
Method	Sterile, indelible ink applied with a marker pen.	Dyes (e.g., methylene blue), sutures, or clips placed internally.	Dyes or sutures applied to excised tissue margins.	Radiopaque markers or specialized imaging techniques intraoperatively.
Application	Performed pre-operatively by the surgeon with patient involvement.	Applied by the surgeon during the procedure.	Applied by the surgeon as the tissue is removed.	Uses techniques like fluoroscopy or ultrasound to guide placement.
Visibility	Must be clearly visible after the skin is prepped and draped.	Used for internal orientation and may not be visible externally.	Ensures pathologist can correctly orient the specimen.	Assists with confirmation of exact level or location intraoperatively.

Addressing Challenges and Improving Compliance

Ensuring consistent compliance with marking protocols faces challenges like time constraints, unusual anatomy, or patient refusal. Healthcare facilities address this through:

Clear Policies: Specific guidelines on which procedures need marking and how it's done.
Education: Training on the protocol's importance and issues like marker permanence or cross-contamination.
Team Communication: Fostering a safety culture where team members can voice concerns about discrepancies.
Checklists: Using checklists to ensure all verification steps, including marking, are completed.

For more guidance on surgical safety, refer to resources like the World Health Organization's Safe Surgery Checklist, which offers detailed instructions for surgical teams.

Ultimately, surgical marking is a robust safety system based on communication, verification, and patient involvement, aimed at ensuring the correct procedure on the right patient at the correct location every time.

World Health Organization: Safe Surgery Checklist

Conclusion

Surgical marking is an essential safety practice in modern medicine. By clearly identifying the operative site, it prevents wrong-site surgeries, improves team communication, and reinforces patient consent. This seemingly simple step is a powerful part of a comprehensive safety protocol, highlighting the medical community's commitment to meticulous patient care.

Frequently Asked Questions

The surgical site is marked by the operating surgeon, who is ultimately responsible for the procedure. This is typically done with the patient's conscious involvement to ensure clarity and informed consent.

Surgical marking is required for any procedure involving laterality (right vs. left), multiple structures (e.g., fingers), or multiple levels (e.g., spine). There are some exceptions, such as single organ cases or procedures where the insertion site is not predetermined.

A special, sterile, and non-toxic ink, often in a marker pen, is used. The ink is designed to withstand the antiseptic skin preparation used during surgery without smudging, ensuring the mark remains visible throughout the procedure.

The 'time out' is a final verification process conducted by the entire surgical team immediately before the first incision. During this pause, the team confirms the correct patient, procedure, and site, cross-referencing it with the surgeon's mark.

While encouraged, patient refusal must be respected. In such cases, the refusal is documented, and the surgical team relies on other verification methods. However, the 'time out' final verification is still a mandatory requirement.

Yes. If a discrepancy is found during the verification process, the case is halted immediately. The issue is reported to the attending physician, and the procedure does not proceed until the discrepancy is resolved.

Yes, surgeons can use internal markers like dyes or sutures for anatomical orientation, or radiopaque markers in conjunction with intraoperative imaging to confirm the precise location of deep tissues or spinal levels.