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Sands said that medical workers used a marker to correctly label the side of the patient that should have been operated on but that, somehow, the surgeon failed to notice the marking. “I think he began prepping without looking for the mark and, for whatever reason, he believed he was on the correct side,” Sands said. Perhaps most crucially, the team of medical workers hovering in the operating room neglected to conduct what’s known as a “time out” before the surgeon first placed his scalpel on the patient. Time outs are safety procedures that require the operating team to verbally call out, “Right patient, right procedure, right location.