Wrong-site surgery has catastrophic consequences for the patient, caregiver, institution, and profession. We present a case in which a healthcare provider initially mistook a tattoo of initials as the actual surgical site marking due to its similarity to the process of initialing the surgical site. Initialing the surgical site may not be an equivocal method of surgical site marking. Healthcare providers’ vigilance over factors that may appear benign is essential for patient safety Financial Support: The Department of Anesthesiology at The University of Illinois Medical Center at Chicago Introduction Tattoos have become increasingly popular. In the United States, more than 45 million people have tattoos 1 . Despite their popularity as well as ornamental and psychological attributes, tattoos carry significant health hazards. These health hazards include infectious risks (hepatitis, HIV), immune reactions, and cutaneous manifestations. Few medical practitioners, however, would envision that a simple facial tattoo opposite an intended surgical site could potentially leave an adolescent male completely blind.We present a case in which a healthcare provider initially mistook a tattoo of initials as the actual surgical site marking due to its similarity to site-marking with initials over the surgical site. The process of marking one’s initials at the surgical site per the recommendations of The Joint Commission’s (JC) Universal Protocol may not, alone, be a fool-proof method of surgical site marking. Case Description An 18 year old male with a left blind, painful, and phthisical eye was scheduled for left enucleation with placement of an orbital implant and left suture tarsorrhaphy under general anesthesia. The patient reported a history of tobacco, alcohol, and substance abuse. The patient had sustained a gunshot wound to the left orbit with a penetrating injury to the left globe, resulting in blindness five months prior to this scheduled surgery. Physical examination was essentially normal except for his ophthalmologic findings, yet revealed a dark blue tattoo by the right eye bearing the initials “ILL”. The left eye was appropriately marked by the surgical service (Figure 1).
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