In a new case study published by the British Medical Journal, healthcare professionals from St. George’s Hospital in London recount a narrowly averted mishap resulting from a patient’s discreet tattoo. The 23-year-old male was sporting ink depicting a play button symbol. Located on the his left pectoral, the symbol appeared to be pointing in the opposite direction of the surgical site — his right arm — causing “quite a stir in the anesthetic room and operating theatre.”

According to the report, the patient was admitted to undergo surgery for a right-side recurrent primary spontaneous pneumothorax. On the eve of the procedure, he consented to having his shoulder marked with an arrow pointing to the intended surgical site.

When he was wheeled into surgery, though, the hand-drawn arrow and the permanent tattoo appeared to be pointing in opposite directions, leading to brief confusion for the healthcare staff.

The authors of the paper shared the story in the hope of reinforcing the need for surgical staff to be mindful in their work, even when tools such as the WHO Surgical Safety Checklist are being employed.

“A checklist is only as good as the team that uses it,” the authors write.

Whatever uncertainty the tattoo caused didn’t last long, and the procedure went smoothly. The patient enjoyed a typical recovery and was discharged two days after the surgery.

“My parents always told me my tattoos would serve as a lesson one day,” the patient jokes. “I don’t think they pictured this. Glad I could provide a source of bemusement and hopefully education.”