PMC9217577_01
PMC9217577_02
The surgical mark for Case 2 visible on the anterior portion of the patient's operative leg, and the mark was easily visible during the performance of the adductor canal block.
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fig1
The surgical site mark was visible (Figure 1).
The patient was repositioned supine. The procedural mark was not visualized during the pause point because the team began to prepare the opposite (left, nonsurgical) leg (Case 2).
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fig2
Before scanning the patient's leg, a pause point was initiated to observe the separate anesthesia procedural marks (Figure 2).
The near-miss was prevented from becoming a wrong-sided block by correctly visualizing the procedural mark on the right (i.e., correct) limb as part of the pause point before the second block (Case 2).
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fig3
The second provider uncovered the opposite leg and visualized the correct surgical limb mark (Figure 3).