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6 Steps to Site Marking Success
Surgeons, staff and patients play important roles in preventing wrong-site surgery.
David Bernard
Publish Date: September 20, 2013   |  Tags:   Patient Safety
site marking ◙ THE RIGHT HAND Site marking represents the patient's voice during the pre-op time out for verification.

The Institute of Medicine's landmark To Err is Human report 14 years ago called attention to the issue of preventable medical errors and sparked numerous patient safety initiatives, including the Universal Protocol and the "Sign Your Site" campaign. In spite of these site-marking safeguards, however, an estimated 40 wrong-site surgeries occur each week, according to the Joint Commission. Clearly, some site confirmation protocols fall short of fail-safe. Employ these strategies to ensure yours isn't one of them.

1 Schedule and verify
Accurately identifying the surgical site should begin at the physician's office, and everyone who plays a part in moving the patient's case to the OR should be fully informed. This includes your facility's scheduler, who is essentially the point of entry for patient information that must be verified all along the way, says Leopoldo Rodriguez, MD, FAAP, medical director and chief of anesthesiology at the Surgery Center of Aventura in Florida.

"The scheduler is the first to verify, on the booking sheet," he says. "They'll record an upcoming knee arthroscopy. Which side? If it's not listed, that should raise a red flag. They should call the physician's office and ask. Schedulers should be on the lookout for any procedure that can be bilateral or performed in multiple areas."

2 Confirm the patient, procedure and site
"Just a few years ago, we'd rely on patients' ID wristbands for identification," says Mary Stewart, RN, BSN, chief clinical officer at the Springfield (Ill.) Clinic. But not anymore. "What if they're not entirely correct? Or what if 2 patients in pre-op share a common name?"

The series of staff members who handle a patient's care throughout the perioperative process should each use all the information cumulatively available to them — schedule, consent form, H&P, communication with the patient — in order to confirm the patient, procedure and site, says John Clarke, MD, a professor of surgery at Philadelphia's Drexel University and clinical director for the Pennsylvania Patient Safety Authority.

A surgeon who asks the nurse, "What does the schedule say?" is erring on more than one level, he notes. "That's one piece of information. You need to gather all the information you can to confirm that it agrees with what you understand to be true. Scribbling from memory is not a fail-safe process."

Individual verification is particularly critical when patients change hands. Dr. Rodriguez cites staff changes during breaks or shift ends as the most common cause of patient identification errors, and urges nurses taking over for others to conduct their own verification of the patient, procedure and site.

patient marks his site ◙ TOTAL SHOULDER At the Surgery Center of Aventura, a patient marks his site (the Y for "Yes"); the anesthesia provider verifies the site and plans the block (the initials SW and the arrow pointing to the block site); and the surgeon's initials (RR) re-verify the site before the patient arrives in the OR.

3 Involve patients
One easy way to get into wrong-site trouble is to neglect patients' participation in their care. "We've seen people go in and mark the site without talking to the patient," says Dr. Clarke. "That eliminates the benefit of verification."

Communication is key. "Site marking is a representation of the patient's voice, particularly during the time out, when the patient is asleep," he says. "You make the mark with the patient, and it is in theory repeating, 'This is where you should operate,' even though the patient can't physically respond."

Just be sure the communications you have with patients are clear, and clearly understood by both parties. "Most of the time, the patient knows where the site is going to be, but not all of the time," says Dr. Clarke.

A physician might operate on the wrong knee if a patient mistakenly points to the limb that's hurting her more on the day of surgery. Someone who isn't clinically trained in anatomy might point inexactly to a site. Meaning can be misconstrued: A patient asked to locate the site isn't necessarily making an indication if they scratch an itch or cross one ankle on top of the other. And consider, says Dr. Clarke, the double meaning in the following exchange:

Surgeon: We're doing the left side today?

Patient: Right.

uniform marking system ◙ RECOGNIZABLE MARKS Establish a uniform marking system at your facility and even among your community's providers to ensure consistent safety.

Dr. Rodriguez recommends putting the marking pen directly into the patient's hand, as the first step in a 4-part verification process. "As long as the patient is a coherent adult, we ask them to mark the site," he says. When the anesthesia provider arrives for the physical assessment, they check the site, initialing it and planning the block. Then the surgeon verifies all the cumulative information and marks the site a third time, with his initials.

"And we're not done yet," he says. In the OR, the circulator verifies everything, and anesthesia can't administer drugs until she's satisfied.

4 Mark consistently
Patient safety authorities advise physicians to mark surgical sites clearly and unambiguously. Adopting a uniform system to signal this information can help ensure surgeons always mark the site right.

Not that long ago, patients used to take it upon themselves to mark their sites at home before presenting for surgery, says Ms. Stewart. This occasionally brought confusion, as when cataract patients disoriented by a mirror's reflection marked the wrong eye. Alternatively, pre-op nurses marked surgical patients. Now, as mandated by authorities' guidelines, the site mark is made either by the physician who'll perform the surgery or a designated first assistant, someone who's guaranteed to attend the procedure.

The physicians operating at her clinic mark the site with their initials, with an X, or with a C for "Correct," but she's aiming to change that. "We prefer initials," she says. "That's our long-term goal. We made it a formal policy this summer, and we're continuing to educate. We're 95% there. We hope to be at 100% by year's end."

Ms. Stewart says consistent marking is worth working for, both at her facility and across town. Her ASC competes with 2 hospitals, where her surgeons occasionally operate. Over the past year, leadership from the 3 facilities hammered out a uniform site-marking protocol for all surgeons to follow.

On the web:

Joint Commission's Universal Protocol: tinyurl.com/775t6s2

World Health Organization's Surgical Safety Checklist: tinyurl.com/42g7qq

Pa. Patient Safety Authority's Wrong-Site Surgery Educational Tools: tinyurl.com/qhrna98

AAOS's "Sign Your Site" Campaign: tinyurl.com/ofc5g6a

5 Keep marked sites in sight
"One of the biggest errors you can make is failing to see the mark during the time out," says Dr. Clarke. If your marker's ink gets washed away by pre-op skin prep solutions, or if the mark is covered by drapes, the all-important reference mark loses its usefulness, and it's easy to lose your orientation when patients are moved, turned over and repositioned for surgical access.

The need for visible site marks presents a particular challenge when a site is not conducive to marking. Genitalia, for example, are difficult to mark. Inking the groin would be conveniently close, but to a booked-up surgeon, the case might be confused with a hernia repair on the schedule and the nearby mark might lead to an off-target incision. Alternatively, you could apply a special wristband or make a mark on the patient's hand, but those areas may end up covered by a drape and remain unseen during the time out.

Establishing a consistent protocol for marking sites in difficult-to-ink areas, and then visualizing them in prepped and draped fields, should be a priority for facilities specializing in general, urological, gynecological and other non-extremity surgeries. "The mark," says Dr. Clarke, "is a way to reinforce safety for the physician in the OR. This is memory refreshed, the verification with the patient."

6 Speak up
The ability to communicate openly depends on each staffer's confidence in their role in the site-marking process. Since every nurse and every tech is charged with ensuring patient safety, they should also have a hand in the progress of the surgical process. "The attitude of 'I'm the doctor, you're the nurse, do what I say,' that has to end," says Dr. Clarke. "We have to create a culture of empowerment. Every person in the process must be able to stop the whole process if they see something wrong. The patient should not go to the room unless everybody agrees."

That's why taking the pre-op time out seriously is among the most important responsibilities surgical team members have, says Ms. Stewart. "Before the incision, everybody should say, 'Stop. What are we doing?' Otherwise we risk just getting robotic, going through the motions, until the time you suddenly realize, 'I just agreed to something that's not right.'"