Preventing Wrong-Site Marking: Communication Checkpoints Before the Patient Hits the OR
By: AORN Staff
Published: 2/6/2026
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Featuring Lisa Spruce, DNP, RN, CNOR, CNS-CP, EBP-C, APRN, FAAN. Lisa is the Senior Director of Evidence-Based Perioperative Practice at AORN. She is also the lead author, AORN Guideline for Team Communication in the AORN Guidelines for Perioperative Practice
Wrong-site marking errors rarely begin with the marker. They usually begin upstream—and the issue cascades unless people, process, and procedures kick in to prevent a bigger problem.
As Lisa Spruce explains, "It usually starts upstream when a procedure is scheduled...then gets compounded in preop holding... and finally slips through during the time-out when attention and shared understanding are incomplete."
So, the fix isn't "mark better." It's communicate better—at every checkpoint.
The common breakdown chain
Spruce describes a typical pattern:
- Scheduling & documentation: Verbal bookings, missing or conflicting orders, laterality abbreviations, or consent that doesn't match the schedule.
- Preop/holding: Consent or H&P not reconciled, images not available, marking not at the true incision, marking without the patient's input, rushed block time-out.
- In the room: A hurried, mechanical time-out; the team isn't engaged; imaging isn't displayed or reviewed together; and no clear permission to stop the line.
This is where team communication matters most: it turns separate tasks into a shared, verified plan.
"How common is it?" and why the standard is still zero
When teams ask if this is rare, Spruce points to Joint Commission sentinel event data: 112 wrong-surgery events in 2023 (8%) and 127 in 2024 (~8%)—with the reminder that reporting is voluntary, so true frequency is likely higher.
Her bottom line is simple: "Wrong site surgeries are ‘never events'... so the standard is zero, regardless of frequency."
The three communication failures that set up wrong-site marking
Spruce names three patterns to watch for:
- Unreconciled documents (schedule vs. consent vs. H&P vs. imaging)
- Mechanical time-out (the team isn't truly engaged)
- Low psychological safety (people hesitate to speak up)
That third one is often the silent risk. Psychological safety doesn't "just happen." It needs intentional leadership and active listening.
The "must-verify" list before the mark
Before the mark is placed, Spruce says teams must verify:
- Patient identity
- Procedure
- Exact site/side/level
- Implants, if applicable
Then reconcile the key sources: consent, schedule, orders, H&P, and imaging.
When documents conflict, her "source of truth" is: signed informed consent + clinical evaluation + authoritative imaging.
Two habits that keep complex cases from "drifting"
For spine levels, bilateral cases, multiple lesions, add-ons—Spruce recommends making the plan visual and shared:
- Image-in-view: display the relevant imaging where the whole team can see it during checklist/time-out.
- Point-and-call: the surgeon (and sometimes the nurse) points to the correct structure on the image and says it out loud while the team confirms.
This turns the checklist from "words on a page" into a spoken, team-confirmed safety step.
Protect the time-out like a critical moment
Distractions kill accuracy. Spruce suggests a "sterile cockpit" during time-out: pause non-essential activity so the team can focus on verifying the patient, procedure, site, and safety details.
Give your team stop-the-line words
Print these. Practice them.
- "Stop. I see a discrepancy between the consent and the schedule."
- "Pause. The mark isn't visible at the proposed incision."
- "Hold. Imaging and documentation don't match."
The quick checklist: 6 ways to prevent wrong-site marking errors
Spruce's "do this every time" list: reconcile the Big Four, involve the patient, mark at the incision, display imaging, use sterile-cockpit time-out, and stop if anything conflicts.
Share with your team—or print and post it where marking and time-out happen.
AORN Guidelines for Perioperative Practice
