Standards of Surgical Site Marking


Visually identifying the spot where the surgeon should make an incision isn’t difficult, but your teams’ firm attention to detail is vital to avoid unspeakable errors.

It’s a simple proposition: mark the site of surgery on the patient so it’s clear where the incision should be made. This seemingly straightforward task is almost always completed successfully, but when things go sideways and the wrong site or side is marked, it can lead to disaster. Imagine your surgeon operating on the left arm instead of the right, the wrong vertebrae, even the wrong patient entirely. These things can happen if the surgical site marking process isn’t airtight. When that fails and a wrong-side, wrong-site, wrong-procedure or wrong-patient event occurs, it not only can be traumatic for the patient and providers involved, but also an extremely costly mistake for your facility.

If your protocols aren’t always followed to the letter, it could be time for a refresher. Thankfully, AORN offers clear guidelines to follow for surgical site marking.

Remove ambiguity

As an evidence-based practice, surgical site marking hasn’t fundamentally changed over the last several years, but that doesn’t make it any less relevant or crucial. “There have not been any new studies or major changes,” says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, senior director of evidence-based perioperative practice with AORN, who coauthored its Team Communication Guideline, which addresses the practice.

The AORN Team Communication guideline notes that verification of patient identity, procedure and procedural site and the marking of the site are regulatory requirements of CMS and all accrediting agencies with CMS deemed status. It also cites The Joint Commission’s Universal Protocol — which provides three-step guidance to prevent wrong-site/procedure/person surgery: pre-procedure verification, patient site marking and a time out — as well as the World Health Organization recommendation of site marking for cases involving laterality or multiple structures/levels.

These guidelines and protocols provide a solid basis for any facility’s site marking policy, and leaders must ensure they know and understand all of their nuances, says Dr. Spruce. “Leaders should make sure it is written in their policies and that their perioperative team members know and follow that policy,” says Dr. Spruce.

“The biggest issue surrounding surgical site marking is assuring compliance with the standardized site marking process,” says AORN’s Team Communication Guideline lead author Mary C. Fearon, RN, MSN, a staff nurse at Swedish Medical Center in Issaquah, Wash., and independent consultant at mmfearon, LLC. “Facilities with high reliable implementation process including compliance review and education of the site marking procedures have decreased incidence of wrong-site surgeries.”

Dr. Spruce says rare but devastating errors often occur when staff don’t adhere to site marking policies and protocols, or are unclear about specifics. The key is not only to have a firm protocol in place, but also to ensure that staff understand why it’s important to follow it to the letter. That means none of the “freelancing” or corner-cutting that can develop among staff in busy, high-throughput environments.

One way to better ensure policy compliance: peer coaching. “Utilize peers to observe the site marking process and then provide feedback on implementation of the process,” says Ms. Fearon.

The finer points

Here are key questions every effective site marking policy should answer clearly:

Who can mark the site? Regulation requires that the procedure site be marked by a licensed independent practitioner who is accountable and present when the procedure is performed. Dr. Spruce calls this requirement “perhaps a common point of failure” in the site marking process.

AORN conditionally recommends that site marking also may be delegated to another person as defined in your organization’s policy, such as a postgraduate medical student who is supervised by the licensed independent practitioner performing the procedure, or a staff member such as advanced practice nurse or physician assistant who has a collaborative or supervisory agreement with the practitioner.

“Ultimately, though, the licensed independent practitioner is accountable for the procedure even if they delegate site marking,” stresses Dr. Spruce.

Where and when should the site be marked? AORN recommends providers mark at or near the procedure site such that the mark will be visible after skin antisepsis and draping. The marker should visible on different skin types as well as after surgical site preparation.

New Research
What About the Marker Itself?

A study published last year in Cureus found that site marking pens may be vehicles for bacterial colonization and transmission even after surgical site preparation with povidone-iodine.

AORN’s Patient Skin Antisepsis Guideline addresses this issue. It recommends that facilities assemble interdisciplinary teams to select surgical site markers based on their effect on the sterility of skin antisepsis, and that any markers used should not promote bacterial growth or transmit infection.

“There is no recommendation on what type of material or pen should be used to mark the site, but it should be made at or near the procedure site and be visible after surgical skin antisepsis and draping,” says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, senior director of evidence-based perioperative practice with AORN. “Most facilities use an indelible marker, but this is not the sole means of marking the site.” Indeed, the AORN recommendation is that marking the site with a nonsterile permanent marker is a safe practice. The guideline cites two quasi-experimental studies that evaluated the effect of site marking on the sterility of skin antisepsis. Both concluded that skin marking with a nonsterile permanent marker did not affect the sterility of skin antisepsis with povidone-iodine, as evidenced by no culture growth at the treated areas.

AORN cites an additional study that suggests that single-use marking pens be considered when a known infection risk exists, such as a procedure involving implants.

Returning to the study referenced at the start of this sidebar, what went wrong? Simply put, don’t reuse site marking pens. “We would never recommend that a marking pen be used repeatedly from patient to patient," says Dr. Spruce. "Marking pens need to be single-use and discarded after marking the patient.”

One final bit of insight from Dr. Spruce: Only use pens designed for the purpose of surgical site marking — never a sharpie or personal ink pen. While that sounds obvious, she says this sometimes happens in the field.

—Joe Paone

Which procedures require it? Dr. Spruce says this is one of the biggest issues surrounding site marking. “Know which procedures always require site marking,” she says, citing the AORN guideline. “At a minimum, it should be performed when there is more than one possible location for the procedure to occur.” Every surgical facility should determine and spell out which procedures require adherence to its site marking policy. “Some facilities will choose to mark all procedures involving an incision or percutaneous punctures, but some exceptions could be procedures involving midline structures, single organ cases, endoscopies without intended laterality, procedures where the insertion site is not predetermined and C-sections,” says Dr. Spruce.

Site Marking
JUST CHECKING Perioperative leaders should periodically ensure that providers are complying with their facility’s standardized site marking process.

One procedural area where site marking can be challenging is spine. For this specialty, AORN recommends that in addition to marking the skin, providers employ intraoperative imaging techniques to determine the exact vertebral level.

Get patients’ attention. AORN recommends that the site marking process involve patients when possible to further minimize risk. If they refuse? Create an alternative marking process for these patients, as well as for sites such as mucosal surfaces and the perineum where it’s anatomically or technically impossible or impractical to mark. This includes cases such as minimal access procedures that involve a lateralized internal organ, or procedures on infants for whom the mark may cause a permanent tattoo. Ultimately, the most important aspect of proper site marking compliance is ensuring that every stakeholder adheres to all three steps of the process defined in the Universal Protocol: pre-procedure verification, patient site marking and a time out. OSM

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