If the Joint Commission's estimate of 40 wrong-site surgeries occurring each week is to be believed, plenty of surgeons are operating on the wrong site or side, what one facility leader called the "scariest scenario" for an OR staff. Wrong-site surgery is easily prevented, say the 560 surgical leaders who responded to our online survey (see "Site-Marking Practices Revealed" on page 30), as long as you focus on these 3 keys to site-marking success.

Patient participation
The Joint Commission's Universal Protocol says patients should be involved in the site-verification process whenever possible, and nearly all of our survey respondents (98%) involve patients in their site-marking practices. Only about one-fourth of respondents use accessories such as adhesive stickers or temporary tattoos, which the Joint Commission says cannot be the sole means of marking a surgical site, to supplement their primary marks.

When patients are brought to the pre-op area of the Ardmore (Okla.) Regional Surgery Center, they're asked to state their full name, date of birth and the procedure that's about to be performed. Pre-op nurses then have them note "yes" next to the correct surgical site before surgeons sign their initials next to the patients' marks, says Tara Flanagan, RN, the center's clinical director.

Make site-marking part of the pre-operative conversation before the patient arrives on the day of surgery to ensure you have the proper side noted on the physicians' orders, says Stuart Katz, MBA, FACHE, CASC, director of the Tucson Orthopaedic Outpatient Surgery Center in Arizona. Then, when the patient is being admitted, have them or their responsible escort mark the site, he adds.

"Patients might think we're going overboard," says Linda Vossler, RN, CNOR, referring to the multiple times they're asked to state their name and the procedure they're about to undergo. "But with the 3 or 4 checkpoints patients must go through before an incision is made," says the director of surgical services at Bert Fish Medical Center in New Smyrna Beach, Fla., "I'm confident someone will catch a mistake along the way."

Ms. Vossler agrees that patient involvement is integral to site-marking success, and advises you make patients active participants in the process. "Don't ask "yes' or "no' questions," she says, warning that some patients, particularly the elderly, might agree with leading questions from your pre-op nurses. "Make them tell you which procedure they're having, including the location."

Surgeon buy-in
Whenever possible, the physician performing the procedure should mark the surgical site, according to the Universal Protocol. In limited circumstances, the guideline states, site marking can be delegated to medical residents, physician assistants or advanced practice registered nurses, but the operating physician is ultimately responsible for ensuring the mark is correct and present. For that reason, most responders (80%) to our survey demand that surgeons mark sites in pre-op before patients are moved to the OR. No mark? No movement.

When site-marking initiatives began to gain steam several years ago, efficient-minded surgeons at Ardmore Regional Surgery Center weren't completely on board with leaving the OR to mark sites on patients in pre-op holding bays — until their pushback began to delay the start of their cases. "The first few times, we had to delay surgery and physically go get them to sign sites," says Ms. Flanagan. "When it cuts into their surgery time, they'll get on board with your initiatives." Plus, she says, it takes only a minute or two to properly confirm and sign the correct site (see "A Sign for Site Markings").

Rachel Hall, RN, points out that keeping your schedule on track and having patients prepped and ready for marking is a key component of correct site identification. Make sure patients arrive in plenty of time for their surgeries so you can get the consent signed, IV started and everything settled with the admission process, suggests Ms. Hall. "This gives the patient time to ask any last-minute questions, and it keeps our docs from having to hurry through the final pre-op assessment and marking process," says the director of the Surgery Center of Middle Tennessee in Columbia.

Clear markings
Unambiguous and consistent site markings must be made at or near the procedure site, according to the Universal Protocol. The marks should also be visible after skin preparation and draping, the guideline states.

A little more than half (55%) of the survey's respondents say surgeons use their initials to identify the surgical site. Others say they mark "yes" (16%) or draw a dotted line (4%) along the intended incision site, both acceptable options according to the Universal Protocol's mandate for clear and concise markings. However, 6% of the respondents say they mark an "X" at the correct site, an ambiguous mark that surgical staff members could mistaken for a warning to not operate where they should. Many respondents say a surgeon's signature or initials are the final check of a multi-step confirmation process that includes notations made by pre-op nurses and patients.

But what if the site is anatomically and technically difficult to mark, as in urologic, gynecologic, spine, laparoscopic and eye procedures? "This topic gets lots of attention, especially when talking about marking spinal levels, internal organs, mucous membranes or procedures done through a scope," says Mary Kline, BSN, manager of the Park Nicollet Ambulatory Surgery in St. Louis Park, Minn.

When faced with sites that can't be marked, rely on patient armbands that contain the information needed to perform a successful pre-procedure time out: the patient's name, the scheduled procedure and the name of the physician performing the procedure. The physician performing the procedure initials the armband to confirm its accuracy, says Pam Kershner, RN, BS, CNOR, perioperative business manager at Schneck Medical Center in Seymour, Ind.

Time to focus
Your surgical team needs to concentrate on marking the correct site before each and every procedure, even in the face of constant time crunches, says Kelli Warden, BSN, RN, CNOR. How long do cases last? How fast can rooms be turned over? When will patients be ready for discharge? "Surgery is measured in minutes," adds the director of surgical services at Southeastern Ohio Regional Medical Center in Cambridge. "Staff feels the strain of getting things done as quickly as possible, and sometimes that causes them to lose track of the safety tools they're supposed to use. And that's when wrong-site Swiss cheese occurs — the holes all line up and something bad happens."