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Archive Staff & Patient Safety 2020

Keys to Site-Marking Success

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

Edward Pollack

Edward Pollack, MD


Pamela Bevelhymer, RN, BSN, CNOR
SIGN YOUR SITE Patient safety experts recommend surgeons mark only the correct surgical site — not where they shouldn't cut.

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.

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