The purpose for this study was to investigate the site marking practice for emergent and non-emergent orthopedic surgery at the authors’ orthopedic teaching program. One author attended surgeries at two hospitals in 2006, documenting the presence or absence of an unambiguous mark in the prepped and draped surgical field. Although emergent and elective cases were “chosen”, there was no intentional selection bias.

Forty-eight surgeries by eleven surgeons were evaluated. After draping a mark was visible in twelve of eighteen (67%) emergent cases, and twenty-seven of thirty (90%) non-emergent cases. In the nine cases in which no mark was visible, two had been draped out, one had been washed off, two had never been marked, and in four cases the cause was uncertain.

The authors would suggest that surgeons were near fully “compliant” with the COA protocol in non-emergent cases, but “complacent” in emergent ones. Wrong site surgery is an event that results in irrevocable harm to the patient - orthopaedic surgeons should recognise the value of pre-operative skin marking for all procedures, and re-evaluate their own personal practices in light of our results.