0
Commentary and Perspective   |    
Reaching Optimal Clarity on Surgical Site MarkingCommentary on an article by Savyasachi C. Thakkar, MD, and Simon C. Mears, MD, PhD: “Visibility of Surgical Site Marking: A Prospective Randomized Trial of Two Skin Preparation Solutions”
J. Lawrence Marsh, MD1
1 University of Iowa Hospitals and Clinics Iowa City, Iowa
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.


Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jan 18;94(2):e10 1-1. doi: 10.2106/JBJS.K.01292
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
For more than a decade, procedures to minimize wrong-site surgery have been instituted, modified, and studied by various groups and organizations. In 2004, The Joint Commission established the Universal Protocol with requirements to verify the patient and surgical site preoperatively, mark the surgical site, and perform a preoperative time-out. The requirement indicates that the mark should be sufficiently permanent to be visible after skin preparation1.
This straightforward and interesting study draws attention to a potential safety issue with the mandated sign-the-site program of the Universal Protocol by demonstrating that there are differences in the potential for erasure of surgical site markings between two common types of skin preparations. The study was well designed to answer the question posed. Three different assessments of surgical site erasure served as outcomes, all of which showed significant differences between the two types of preparation. The authors concluded that the chlorhexidine-based preparation resulted in considerably more erasure of the surgical site marking than the iodine-based preparation.
In deciding how important the threat of erasure of a surgical site marking is to patient safety, a couple of issues are relevant. In a recent study that queried the Part II (case list) database of the American Board of Orthopaedic Surgery, the number of occurrences of wrong-site surgery was found to be extremely low and the most common area affected was identification of the vertebral level in the spine—a wrong-site error that cannot be prevented by skin marking regardless of its clarity2. Analysis of the data over time showed that the Universal Protocol of The Joint Commission had not significantly decreased the very low rate of wrong-site surgery. It is reasonable to ask whether additional layers of precautions such as more detailed time-out procedures and checklists or whether further efforts to maintain optimal clarity of the surgical site mark after preparing the patient can eliminate or further minimize the occurrence of wrong-site surgery.
In addition, how clear does the surgical site marking need to be? In most orthopaedic procedures, the site only needs to be identified. Marking does not determine the type of procedure, does not mark out flaps or incision sites, and does not determine implants. The signed site does not need to convey any substantial information. To do its job, the mark only needs to be visible—not crisp, clear, or perfectly defined. Typically, the site is initialed, but the operative team does not try to read the initials. The current study did not assess whether, after skin preparation with the chlorhexidine-based solution, the surgical site marking was not visible; only that it was less clear than after preparation with the iodine-based solution. The question of how clear it needs to be to correctly identify the site was not addressed.
Despite these issues, surgical site marking is required and is generally thought to increase patient safety in the operating-room environment. The authors showed that the type of preparation makes a difference in the visibility of the site mark, and there are few downsides to having the mark appear as clear as possible. The potential for mark erasure should be considered when a surgical skin preparation is chosen, and as the authors suggest, further investigation is warranted to develop a marking method that resists erasure and/or a surgical preparation that is optimal for infection control and maintains visibility of the surgical site mark.
The Joint Commission. Accreditation program: hospital. National patient safety goals.  2011 Jan 1. www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed 2011 Sep 22.
 
James  MA;  Seiler  JG  3rd;  Harrast  JJ;  Emery  S;  Hurwitz  S. The occurrence of wrong site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am.   In press.
 

Submit a comment

References

The Joint Commission. Accreditation program: hospital. National patient safety goals.  2011 Jan 1. www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed 2011 Sep 22.
 
James  MA;  Seiler  JG  3rd;  Harrast  JJ;  Emery  S;  Hurwitz  S. The occurrence of wrong site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am.   In press.
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Related Audio and Videos
PubMed Articles
Guidelines
Surgical site infection: prevention and treatment of surgical site infection. -National Collaborating Centre for Women's and Children's Health | 5/1/2009
Results provided by:
PubMed
Clinical Trials
Readers of This Also Read...
JBJS Jobs
02/28/2014
DC - Children's National Medical Center
03/26/2014
MA - Boston University Orthopedic Surgical Associates
04/02/2014
WY - Memorial Hospital of Sweetwater County