Perhaps no act committed in the OR has been the subject of more scrutiny and study than that of the surgeon scribbling his initials in purple ink on the patient's skin to mark the surgical site. So simple a caveman could do it, right? And yet every year an estimated 1,300 to 2,700 wrong-site surgeries occur in the United States, many of them attributed to how the site was marked. Or wasn't.

How can you screw up something as simple as writing your name?

Is it carelessness or so-called human error? Is it beneath the busy, brilliant surgeon to hold a magic marker in his hand rather than a scalpel? Is verifying the site in pre-op and taking a time out before the procedure begins like looking both ways before you cross the street? Yeah, your OR team does it, but maybe without much thought and never the same way twice.

Those might be contributing factors. But the real reasons appear to be these: an aversion to following directions, a failure to standardize surgical safety and a lack of conviction to do something about it.

The Joint Commission's Universal Protocol explicitly spells out the who, what, when, where and why of surgical site marking, the best defense you have against wrong-site surgery. But the protocol is weakened every time you deviate from it, every time the surgeon in OR1 writes "yes" before induction and the surgeon in OR2 writes his initials after induction, every time the team in OR3 covers the mark with drapes and the team in OR4 fails to refer to the site at the time of laterality identification.

Above all, "we're looking for consistency of process across the institution," Peter Angood, MD, vice president and chief patient safety officer for the Joint Commission, tells our David Bernard in "Site Marking Q&A" on page 45.

Safety should be constant and unchanging, routinely and religiously following the same steps in the same sequence every time. In "Surgical Safety? Check!" on page 19, you'll find a checklist you can hang by the OR table that will help ensure that your team does just that under any circumstance.

We've promoted deviant safety behavior, which anesthesiologist Gil Samson, MD, of Winthrop-University Hospital ASC in Mineola, N.Y., politely pointed out to us. "Administer the first block of the day before the skeptical surgeon even arrives," reads a sentence in "The Path to Regional Success" (October, page 47). Oops, guilty as charged.

"Our hospital won't let anybody but the surgeon mark the operative site with his initials, so no sedation or procedure can begin before he arrives," says Dr. Samson. "We should have a nationwide blanket policy on laterality identification."

You do. It's up to each of you to follow it.