Background: All general radiographic images must always display a correct permanent anatomical side marker (ASM). However, literature reports a decline in the use of permanent ASMs in digital radiography (DR). The ASM has been reported as one of the most common sources of error in radiography of which some have resulted in performing wrong-site surgery and treatment. Since the installation of a DR X-ray machine in 2015 at the University Teaching Hospital (UTH) no research or audit has been conducted on this subject. Aim: This study aimed at auditing the use of ASMs in digital radiography (DR) and identifying the barriers to the use of permanent ASMs at the University Teaching Hospital (UTH) of Lusaka, Zambia. Methodology: This study was conducted in two phases. The first phase involved a retrospective auditing of the use of ASMs in DR with a sample of 290 radiographic images. Data were collected using a checklist. The second phase was aimed at identifying the barriers to the use of permanent ASMs and suggestions to overcome them. Data were collected using an online questionnaire. Quantitative data were analysed using descriptive statistics, whilst qualitative data from open-ended questions were analysed using content analysis. Results: In the first phase, all the audited images N=290 (100.0%) had electronic (digital) ASMs and were placed on the correct anatomical side (right or left). However, no image had a permanent ASM. A total of N=45 (18.8%) images had ASMs that obscured the anatomy. In the second phase, a total of N=20 (46.0%) respondents agreed that they do not always use permanent ASMs because of a lack of ASMs, increased workload, and time-consuming. Conclusion: This study revealed the non-use of permanent ASMs by radiographers and radiography students. The purchasing of permanent ASMs and delivery of educational awareness programme is recommended as well as frequent auditing.