CUT WHERE? Surgical site marking can vary greatly, with smiley faces, asterisks and arrows among the many symbols used to note the proposed incision.

How do your doctors mark the surgical site? There are only 2 correct answers, only 2 virtually unmistakable and universally accepted ways to identify the correct site — write yes or the surgeon's initials at the site of the incision. But depending on which OR you're in and which surgeon happens to be holding the permanent marker, you're just as likely to see or as what you're supposed to see: yes or the surgeon's initials (or both).

Just like your patients, site marks come in all shapes and sizes. Several unorthodox methods of marking reared their purple heads in our survey of more than 550 Outpatient Surgery Magazine readers. A small sampling:

• smiley faces and bull's-eyes, colored stickers and checkmarks;
• lines and arrows pointing to the proposed incision, asterisks and stars; and
• the surgeon's initials, the nurse's initials, the patient's initials (see "Should Patients Participate in Site Marking?") or some combination thereof.

No exceptions
In an ideal world, as one reader put it, "every patient would be marked by the same person the same way — no choices and no exceptions."

Nearly three-fourths (71.3%) of the 564 surgical facility managers we surveyed adhere to the Universal Protocol by writing either the surgeon's initials (55.1%) or yes (16.2%) large and legibly to identify the surgical site.

But for a sizable portion of our respondents, site marking is a curious chance to freelance rather than being the standardized practice it should be. When we asked a hospital administrator to describe the site-marking protocol at her facility, she couldn't give us a definitive answer. "It varies depending on the case," she says. "Some doctors use x, some use their initials." Says another: "Initials or a suitable mark — it varies by surgeon." Your guess is as good as ours what constitutes a suitable site mark in that OR.

Orthopedic surgeon John D. Kelly IV, MD, a sports shoulder specialist from Philadelphia, Pa., marks the site as it should be done. He uses a non-fading, one-time-use surgical marker to write his initials on the site, and then operates through or adjacent to his initials. "It creates a thick and legible line and it's sterile," he says. "Writing yes or one's initials eliminates confusion." Unless, of course, your doctor's name is Nick O'Brien or Nate Oswalt, in which his case marking the site with your initials would spell no and leave you with more questions than answers.

PATIENT INVOLVEMENT
Should Patients Participate in Site Marking?

If you're not making your patients active participants in your site-marking process, you should be. To what extent is a topic for debate. Should they verbally confirm the correct site, side and procedure, or draw the mark themselves? Depends on whom you ask.

PATIENT PARTICIPATION Marking should take place with the patient involved, awake and aware, if possible.

The Ardmore (Okla.) Regional Medical Center asks patients to write their initials near the incision site followed by the surgeon writing his initials near the incision site. Tara Flanagan, RN, Ardmore Regional's clinical director, explains. "When we bring patients to the pre-op area, we have them state their full name, DOB and the procedure to be performed. At this time we have them mark the surgical site with a non-fading, one-time-use marker. When the surgeon visits the patient before surgery, he then initials the patients' yes," says Ms. Flanagan.

Similarly, patients at the Prairie Surgery Center in Springfield, Ill., mark their surgical sites with dots. "The surgeon then must mark the patients with his initials before the patient is taken back to the OR," says Clinical Director Sarah Hilligoss, RN, BSN. They follow the same formula at Clarkston (Mich.) Surgery Center, except patients pre-mark their sites with an x before physicians confer with the patients and mark sites with their initials, says Administrator Pam Simmons.

The patient should be involved in site marking if possible, but the attending surgeon should be the one to mark the site, says Margaret Sherman, RN, BSN, the nursing director of the Hamilton (N.J.) Endoscopy & Surgery Center. "The patient should verbalize the site upon entry into the OR and the time out should be performed immediately before incision by the whole surgical team, led by the RN using the consent, the anesthetist at the armband and the surgeon at the surgical site," she says.

Two important distinctions: One, don't ask the patient to mark the right site. Instead, ask the patient to mark the correct site. Using right or left can cause confusion. Two, be sure patients aren't sedated when you ask them to participate in the marking process.

— Dan O'Connor

Risk factor for wrong-site surgery
Consistent site marking is critical. The method of marking and type of mark should be consistent throughout your facility, safety experts say. Nearly 9 out of 10 (88%) of our survey respondents say that their marking methods and marks are standardized for all cases. That in itself is good patient safety news, even if some surgeons are doodling 's or 's rather than YES or their initials.

"Marking operative sites should be performed in a consistent manner throughout the [facility] so that everyone understands the significance of an X or YES or NO or any other symbol that you use," says Godofredo Herzog, MD, an anesthesiologist and accreditation consultant.

WITHOUT A DOUBT Make sure site marking is always done, properly, consistently and recognizably.

Many view deviating from a designated, standardized identifier for the correct surgical site and allowing exceptions to the rule as an invitation for wrong-site surgery to occur on your watch. Could even a small deviation cause confusion? Well, consider this scenario. One facility's routine is for the surgeon to mark the site with his initials and the nurse to then mark it with an X. At the hospital across town, however, they mark the non-operative limb with an X. Does X mark the spot or not? Many say inadequate, inaccurate or ambiguous surgical site marking is a major risk factor for wrong-site surgery.

"Universal marking procedures should be just that: universal. An agreed-upon convention amongst the professional societies is not just a must, it's an obligation to the patient," says Spence Byrum, a high-reliability-organization expert and former Coast Guard pilot who teaches healthcare facilities how to eliminate avoidable errors. "Variations in site marking are the equivalent of asking people what a stop sign should look like. Can you imagine the chaos if each individual, each city, each state, each country was allowed to chose what their interpretation of a stop sign should look like?"

Keep in mind, adds Mr. Byrum, that many of your surgeons and maybe some of your staff routinely operate in facilities other than yours. "The need for a consistent marking convention is imperative," he says. "Expecting them to remember what constitutes a properly marked site at each facility is foolishness. And anyone saying that the site does not need to be marked is in the wrong business."

Jack Egnatinsky, MD, an anesthesiologist and an accreditation surveyor for AAAHC, also stresses the importance of standardizing the way you mark the site, be it with a YES or the surgeons' initials. "YES at the site may work, but only if the other side is marked NO. An X is not a good mark," says Dr. Egnatisnky. "And be sure that the site marking is done with a marker that will withstand the surgical skin preparation."

One facility manager in our survey says that different surgeons are allowed to use different site-marking methods. Her ophthalmologist places a dot above the operative eye, her orthopedic surgeon uses yes and her general surgeon draws a line along the proposed incision.

"You have to empower your nurses to be consistent and hold surgeons accountable in the site marking for it to work on a consistent basis," says Kelli Warden, BSN, RN, CNOR, director of surgical services at Southeastern Ohio Regional Medical Center in Cambridge, Ohio.

Be sure the mark is visible after the patient is prepped and draped. Nearly half (46.3%) of those we surveyed say markings become less visible after skin prep solution is applied around the planned incision site. This presents a real danger, as surgeons may operate on non-marked sites under the faulty assumption that the site marking had been washed off during the surgical preparation. "If a site marking is not seen during the pre-surgical pause, everything stops," says Linda W. Frix, RN, BSN, CAPA, clinical director of the Northern Virginia Surgery Center in Fairfax, Va.

Site Marked and Verified
8 Practical Tips to Mark the Site Right

1. Cleaning the skin with alcohol and letting it dry before applying the mark will help the ink adhere to the skin
2. Be sure the site mark remains visible after you've prepped and draped the patient.
3. Don't let patients leave the pre-operative holding area unless they've been marked.
4. Don't use the same sterile marking pen on more than 1 patient.
5. Don't mark any non-operative site(s). This will create confusion and increase the risk of wrong-sided surgery.
6. Don't use adhesive site markers or temporary tattoos as the sole means of marking the site. They're meant to supplement primary marks.
7. Final verification of the site mark should take place during the pre-op time out.
8. Ideally, the lead surgeon should mark the site, not the nurse and not the anesthetist, unless he's marking the site for a block

Source: Outpatient Surgery Magazine Reader Survey

Following protocol
The Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery involves 3 simple steps: surgical site marking, pre-operative verification and a time out. Despite the mandatory and widespread implementation of the Universal Protocol since 2004, it's estimated that wrong-site, wrong-side and wrong-patient procedures occur more than 40 times every week. It's safe to wonder whether we should indict ambiguous site marking in the continued problem of wrong-site surgery.

"Let's take site marking for our patients as seriously as we would take it if one of our loved ones was on the table, and make sure it's always done, properly, consistently and recognizably," says Mr. Byrum. "Let's focus on the autonomy that might be required to accomplish the procedure and not on the autonomy of individual site marking conventions that regularly contribute to wrong sites. Wrong sites need to be eliminated, not reduced."