Surgeon or nurse should mark the operative site

At a recent press conference concerning the Universal Protocol to prevent wrong-site surgery, proponents answered some of the most frequent questions about how to follow the protocol:

Question: Is it necessary for the surgeon to mark the operative site or would it be acceptable for the patient to write the word "yes" on the operative site? How about having a nurse do it?

Answer: James H. Herndon, MD, president of the Rosemont, IL-based American Academy of Orthopaedic Surgeons, says research shows that patients cannot be trusted to mark the site themselves. "They often are incorrect, forgot or got confused about which foot was going to be operated on," he says. "Therefore, I don’t think you can trust patients to do the signing for you. It has to be a joint process between the patient and the treating physician. Our academy feels the surgeons themselves should sign the operative site, but others don’t feel that strongly. But it has to be a joint effort between the patient and whoever is authorized to sign the site."

Thomas R. Russell, MD, FACS, executive director of the American College of Surgeons in Chicago, says surgeons should sign the site themselves.

Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, says his organization expects the patient to be involved but not actually signing the site. "Involvement of the patient means the patient should actually be interacting, but it does not mean the patient is actually marking the surgical site. The expectation is that to every extent possible, the surgeon should be the one marking the site; but failing that, it should be someone who is going to be in the operating theater as part of the surgical team."

Question: Are you supposed to mark the actual incision site or just more generally on the correct limb?

Answer: O’Leary says the marking should be "as close to the site as possible. If the question implies whether there is any infection risk, that has never been documented."

Herndon notes that the proximity to the actual incision site can make a difference. He cites a case in Florida in which a patient was to have surgery on one heel, and the surgeon correctly signed that foot to indicate the operative site. But the patient was turned over on his stomach for the surgery, placing the other heel on that side of the operating table. The surgeon’s signature was covered with drapes, so no one noticed the error, and the procedure was performed on the wrong foot. "So if the initials were nearer the site of the surgery, that could have been prevented," he says.

Question: Is it necessary to mark the operative site for midline procedures and orifices, since you can’t really confuse right and left?

Answer: JCAHO takes a conservative approach and encourages marking of all sites unless there is obviously no room for confusion, O’Leary says. But he cautions that even midline procedures can result in wrong-site errors, such as approaching a spinal operation from the wrong side.

Russell notes that the Universal Protocol does not require marking midline procedures because many surgeons resisted the idea and the ACS wanted to encourage participation.

Question: What about high-volume situations in which the surgeon is doing the same procedure over and over? Is it still necessary to mark the site and follow the rest of the protocol?

Answer: Yes. Russell says high volume is no excuse to not mark the site. "High-volume surgeons are at risk. You may be high volume one day; and if you do a wrong-site surgery, you may not be high volume the next day," he says. "Our protocol at ACS calls for surgeons to do it, and being too busy with a high volume of surgeries doesn’t change that."