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.