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The Ink Must Go Where the Knife Will Cut
There'll be less wrong-site surgery if your surgeons cut through their initials.
Richard Abowitz
Publish Date: April 8, 2018   |  Tags:   Patient Safety
Initial Cut
INITIAL CUT The most important site marking tip: initial where you cut.

Cut through your initials. Initial where you cut. Sign your site. However you say it, the meaning is clear. Surgeons use an indelible skin marker to write the first letter of their first and last name on the surgical site, and then make an incision through the ink, as if it were a bull's eye. If every surgeon would do that one simple thing every time, the safety experts say there'd be a lot fewer wrong-site surgeries.

WASH AWAY? Use an indelible marker to mark the site to ensure that the pre-op skin prep solution doesn't wash away the mark.

Sounds simple, right? But every year, U.S. surgeons perform about 2,000 incorrect operations. Perhaps the best known case is one you've probably heard before. Hand and arm surgeon David Ring, MD, PhD, performed a carpal tunnel release instead of a trigger finger release on a 65-year-old female patient.

Dr. Ring famously broke the silence that surrounds surgeon errors when he issued a public mea culpa in the Nov. 11, 2010, edition of the New England Journal of Medicine (osmag.net/SG2tvD), sharing in great detail with his fellow docs the missteps that led to his error. Dr. Ring has since lectured and written about wrong-site surgery countless times, along the way becoming, as he puts it, "the poster child for operating on the wrong body part."

Dr. Ring was a proponent of the "sign your site" protocol before his wrong-site error. But hospital policy was for a nurse or a surgeon to mark the limb, not the site. In Dr. Ring's wrong-site case, a nurse had marked the correct arm at the wrist, but not the planned incision site on the hand.

Dr. Ring gives credence to using checklists and hard-stop time outs. He also has a few rules on site-marking:

  • The surgeon must make the mark, but only after confirming the indication (appropriateness), affirming the patient's desire for surgery (consent), and verifying the site and the surgery with the patient and on the consent form.
  • The ink must go where the knife will cut. It should be a bull's-eye that draws the attention of the surgeon and team to the correct side, site and surgery. It cannot go nearby on the limb.
  • If there is not ink where the consent and the team say the cut should be made, the surgery should not proceed.

"But in a busy OR, if a surgeon doesn't put the ink on the absolute exact spot where he is going to cut through, people will often just accept that variation," says Dr. Ring. "It is surprising how hard it can be to speak up."

In this way, a safety feature is compromised, because of the natural tendency of people not to express a concern that could be dismissed as petty.

Dr. Ring's final words to his colleagues in the New England Journal of Medicine dispel that notion: "I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson."

More practical pearls

BLUE SHIELD When patients can't be marked, a banded extremity verifies the surgical site.

Human error is reducible, but not unavoidable. One study claims communication failures were the root cause of 70% of wrong-site surgeries. Here are 7 reader-supplied tips to support your culture of safety.

  • Pick one. There are only 2 acceptable ways to mark the site — the surgeon's initials (unless they're NO) or the word YES.
  • Use waterproof ink. Use an indelible marker to mark the site to ensure that the pre-op skin prep solution doesn't wash away the mark.
  • Not the time for individual expression. Surgical site marking is not a time to draw cutesy symbols and squiggly lines — those marks will only confuse the surgical team when they're confirming where the cut should be made.
  • Adopt a "no-mark, no-surgery" policy. Don't let anybody but the surgeon mark the operative site before the induction of anesthesia. No sedation or procedure can begin before the surgeon arrives.
  • X does not mark the spot. Do not mark non-procedure sides or sites with an X, which can easily be mistaken for the surgical site. The unnecessary marking could be misinterpreted as a warning indicating the non-operative site or as the place to cut. Avoid either scenario.
  • When the surgical site is unmarkable. For certain procedures, you can't mark the skin at a surgical site (examples: dental or oral surgery, or a procedure in a mucosal area or the perineum). Mark un-markable patients by affixing a bright blue extremity band near the site. On the band, the attending physician writes the procedure, side, site and his initials.
  • We're doing the left side, right? Rather than refer to "the right side" or "the left side" when asking patients to confirm the correct side and site for surgery, it's better instead to use "correct side" and "correct site." Is there anything more confusing than asking a scared patient, "We are doing the left side, right?" OSM