case_images: PMC9217577_01
case_images: PMC9217577_02
case_images: 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.
case_images: CRIA2022-1541827.001.jpg
case_images: PMC9217577_02_CRIA2022-1541827.001.jpg
case_images: fig1
case_images: The surgical site mark was visible (Figure 1).
case_images: 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).
case_images: CRIA2022-1541827.002.jpg
case_images: PMC9217577_02_CRIA2022-1541827.002.jpg
case_images: fig2
case_images: Before scanning the patient's leg, a pause point was initiated to observe the separate anesthesia procedural marks (Figure 2).
case_images: 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).
case_images: CRIA2022-1541827.003.jpg
case_images: PMC9217577_02_CRIA2022-1541827.003.jpg
case_images: fig3
case_images: The second provider uncovered the opposite leg and visualized the correct surgical limb mark (Figure 3).