Keys to Site-Marking Success


Consistent protocols and a transparent work environment will prevent wrong-site surgeries at your facility.

Wrong-site surgeries occur approximately 40 times a week in facilities across the U.S. Surgical professionals must therefore ask themselves why these avoidable errors continue to be an issue despite increased efforts to correct the problem, and what can be done to limit or prevent them from happening.

A major issue is that there is no single root cause of wrong-site surgery. However, the Joint Commission has noticed common themes during reviews of incidents, including communication errors, hand-off errors, confirmation bias and consent that is either unclear, illegible or not specific enough. For instance, cases where the correct side or site isn't noted in pre-op paperwork.

One of the most effective ways to eliminate wrong-site surgery is to follow the long-standing Universal Protocol, which addresses proven methods to ensure surgeons make the correct cut during every case. Make sure the three primary components of the Universal Protocol are in place at your facility.

  • Establish a verification process. Providers need to understand that each step within the Universal Protocol is crucial in preventing wrong-site surgery. Through the targeted solutions tools that The Joint Commission developed, we closely looked at wrong-site surgeries and found that the defect is often upstream — even in the office that produced the consent form. Errors can occur in the OR if notes from surgeons' offices are incorrect or include last-minute changes, or if the order of the patients in the OR schedule changes without the care team being notified. Put a process in place to confirm the correct patient, procedure and surgical site are noted on consent forms, the surgical schedule and pre-op paperwork before patients arrive for surgery.
  • Mark the surgical site. The area where we see the most variability is during the time-out process because it's highly dependent on workflow (more on that later), but there are also inconsistencies in terms of who marks the site and how they do it.

It's imperative to establish standards that are clear and unambiguous. However, the variability surrounding site marking can be problematic. For example, if certain team members are used to one convention for site-marking, but then move to a different facility where the standards are completely different, there is more room for error. Additionally, a surgeon might mark the surgical site with their initials, with a check mark or by circling the area — it really comes down to their facility's policy. The most common policy requires surgeons to mark sites with their initials.

There are clear recommendations from patient safety experts that surgeons should never write "no" on the incorrect site. They should mark only the site they're going to work on because marking another area could create unnecessary confusion.

Yes, it certainly would be easier if there were a national consensus surrounding site-marking. Still, you can greatly reduce potential issues by establishing a single process that is well-known and understood by every surgeon and staff member — and making sure it's consistently enforced.

Site-marking should occur in pre-op holding and should be done only after relevant pre-op images, surgical notes and consent forms have been reviewed — and in collaboration with an awake, alert patient before sedation. If possible, it should also include family members of the patient. Site-marking should be done with reference to what's called the "source of truth," which is typically a consent form that is marked with the correct site and completed only by the surgeon performing the procedure. Indelible marker, which won't wipe away when an alcohol-based prep is applied, should always be used to mark sites.

Confirm the Correct Site Every Time
HUDDLE UP Promote behaviors that support a culture of safety and teamwork.

Putting protocols in place to prevent wrong-site surgery might require a few organizational modifications. Start with these essential steps.

  • Encourage organizational leadership. Promote behaviors that support a culture of safety and teamwork, which includes engagement of the whole team — including the patient and the family — and appropriate staffing and workflow.
  • Promote staff engagement. Establish "good catch" programs and an anonymous incident reporting system where staff are rewarded for entering unsafe conditions, which could include a time-out when the team wasn't engaged in the process. These methods are not meant to be used as a punitive way to get colleagues in trouble, but rather to coach staff members and use an incident as a moment of learning before it becomes a problem.
  • Be transparent. Transparency should be a key value within a healthcare organization. Staff should be encouraged to speak up anytime they witness an error or an unsafe condition.

—Edward Pollak, MD

Be aware of risk factors associated with site markings. Errors can occur because some sites are intrinsically difficult to mark, such as the spine. The skin site does not correspond to the spine level, so marking the skin is insufficient. The physician needs to review the patient's radiology imaging, but imaging while the patient is positioned for surgery is not always clear. Having more than one person reviewing the film can help, but during many procedures, there is often only one team member who is experienced enough to interpret the imaging to determine the correct spine level.

  • Perform a time-out. Ultimately, you need to establish a safety culture by improving communication within teams. This means not just improving clarity of team communication, but also encouraging all members of the team to speak up. Every member of your staff should feel empowered to voice their concerns about patient safety without fear of retribution, even if they're wrong. This is a crucial step in preventing wrong-site surgery.

Your facility should have a zero-tolerance policy for intimidating behavior and should create an environment where all team members believe their thoughts and ideas matter. The leader in the OR — whether it's the surgeon, attending surgeon or anesthesiologist — needs to encourage all team members to feel included in the pre-op time-out process. This can be done by allowing everyone to introduce themselves, identify what their role will be during the procedure and actively participate in the confirmation of the correct surgical site.

Due diligence

Making sure surgeons perform the correct procedure on the correct patient at the correct site demands a coordinated and transparent effort from every team member in your facility. The steps to prevent wrong-site surgeries are more common sense than complex, but implementing them on a daily basis can be challenging. Refocus your efforts and recommit to ensuring the never events that keep happening in facilities across the country don't occur in your ORs. OSM

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