Surgical Site Marking

OBJECTIVES
• To ensure that all operating theater staffs are equipped
with the necessary knowledge and information on the
implementation of correct surgical site marking on all
surgical cases with exception on special cases.
• At the end of this session, all operating theater staffs will
assert that site marking is done correctly on all surgical
cases in which site marking is mandatory. Hence, 100
percent compliance rate.
 Quality Performance
Purpose Indicator
Surgical site marking is one of the key points in the WHO surgical safety checklist. It is a
vital part of the preoperative verification process to prevent surgical error specifically
• Marking of the operative site and side with the
wrong site and side of surgery.
use surgical pen.
Target/Threshold
• Site and side marking must be completed by the
100 Percent
Surgeon with the patient involvement, as
applicable, as per the best practices on Surgical
Ward with flexibility on exceptional cases in Pre-
Operative Unit.
 FORMULA
Total number of operations with applicable
Audit Site Marking Done at a given period of time
------------------------------------------------------------------------ x 100
Total number of operations with applicable site marking
at the same period of time

Monthly Quarterly Yearly

 March April May June

70 Percent 71 Percent 89 Percent

79 Percent
*100 *100 *100
*93 Percent
Percent Percent Percent
 Surgical Site Marking
102
Inclusions
100 March April May June
All Cases 70% 79% 71% 89%
98
Excludes Dental and 100% 93% 95% 94%
Urology Cases
96 Surgical Site Marking
94
92
90
88
March April May June
 Definition
Contents
of Terms

  
Surgical Site Marking:
4.
3.
2. Verification
-It is amarks?
Who
How vital part
and where of the to
With preoperative
whom?
mark? verification process in which it's main objective
1.
-The
is Whensurgical
to prevent to mark?
wrong site
sitemark Before
should
of surgical patient’s
ItSurgeon’s
subsequently
procedure. is done bytransfer
Surgeon
be Initial
checked
marking tototheater
confirm
the operative site
-The
--with
Markingsite should
Marking
a surgical is
pencarried
should be
be marked
outbyout
carried
as identified by
theout the
after
before
surgeon. operating
patient surgeon
all available who
information
transfer to will
theater
that
be the site marked
ultimately accountableis correctly
for located
the as written on the patient's
surgery.
concerning
Laterality
and ideally
file and if
the patient's
before
possible sedative
as
identity,
pre-medication
identified by the
the procedure
is given.
patient, and if
and
Thus,
the
the
ideally
mark is it
-Refers to a side of the body/anatomy specifically left or right
-The
surgical
should process of in
besite/intended
Level visible. done pre-operative
the ward.side has marking of the intended
been checked site
and verified.
still
should
-It
The
-In spinal involve
is surgeon's
the surgeries, athe
levelpatient/and
responsibility
initial ofoccur oraffixed
the pre-operative
should
corresponds be
to familyon members
nurse
the or significant
to remind the
-The verification should atthe vertebra.
each patient transfer specifically
others
Discrepancy
ward whenever
nurse
incision/insertion
during “Sign ofIn”the and
possible.
site
site marking.
or
finally atIf least
inConsequently,
during
cases6
“Time
of Out”.
spinal
inches it surgeries,
from is the
the site
operative
-A discrepancy corresponds to three possible cases:
marking
responsibility
site.
-The
1. DuringUnless
persons should be information
of the
the
clinically
responsible
verification, done
ward by the
nurse
necessary,
for the
is surgeon
notto inform
no other
verification
consistent. together
and is reminds
point withthe
should the
the pre-operativebe
surgeon
members
2. of
The verification
marked
nurse, and the
of
besides
the is need
the for
notsurgical
done.
the
checklist site
team
surgical marking.
and the
site.
coordinator, theradiographer.
circulating nurse.
3. The process has not been performed properly.
 Exceptions to Surgical Site Marking
5. 1. Life-threatening
Simultaneous emergencies
bilateral surgery
6. Wounds or lesions,emergencies
-Life-threatening and mucousinmembranes
which the time required for marking creates an
-Marking
additionalis risk
not toneeded for obvious
the patient. wounds/lesions.
The risk However,
and benefits must if there
be assessed aresurgeon.
by the multiple
lesions and11.
2. PrematureonlyENTsomesurgery
infants will be treated, Exception:
then site marking is necessary.
Ear Surgeries
7. Cases in which
-Marking -However,
may the
cause ear surgeries
laterality must be
a permanent require site
confirmed
tattoo. marking
under anesthesia or investigation
8. 3.
Laparoscopy/Minimally
Dental Surgeryespecially if invasive surgical
only one side procedures.
will be operated.
-For intended 12. treatment
Procedures of ona lateral internal
midline organsorgan,
suchwhether via percutaneous
asaumbilical,
-No practical or reliable method for directly marking tooth. Dental panoramic
approach or a natural
perineal,
radiogram orifice, the mark
may beanal-vaginal
used. can be
or penile made at or near the site indicating the
areas.
side t be reached.
4. Endoscopy/Interventional cases
9.Single organ cases
-Minimally invasive procedures as in cardiac catheterization.
10. Lumpectomy in breasts (Non-palpable)
-Non-palpable mass is marked using ultrasound guidance.
 Special Cases on Site Marking
1. Opthalmology
-Betadine may be used as a means of marking
instead of a surgical pen marker.
-A small mark may be made either on the forehead
above the correct eye, or on the lateral aspect of
the eye between the lateral canthus and the ear.
2. Spinal Surgeries
-Special intra-operative radiographic techniques are used to mark
the exact level of the spine.
3. Urology
-C-arm and PACS equipments in theater may be used. Mark
should be done on the abdominal area where the ureter/organ
side within the draped area.
4. Orthopedics
-Digital surgery: each and every digit to be operated on must be
individually marked.
 Key Points
Identify procedures that require surgical site marking of the
The method of site marking is unambiguous and is used
incision or the insertion site. Sites are marked when there is
consistently. It should be the surgeon's initial.
more than one possible location.

The
Markmark
the should
procedurebe visible
site before
even the
afterprocedure
skin preparation
is performed
and and
draping. A sufficiently
if possible,permanent
with the patient's
markerinvolvement
must be used.

Marking should be done in such a way that when a patient/limb

The procedure site should be marked by the operating surgeon
is repositioned, the mark is still clearly visible.
who is ultimately accountable for the procedure.
 References
• High 5's: Action on Patient Safety. Joint Commission Guidelines.
Guidelines for Implemntation of the Universal protocol for the
Prevention of Wrong Site, Wrong Procedure, and Wrong Person.
Website: www.jointcommission.org/assets/1/18/universalprotocol.pdf
• National Patient Safety Goals. National Patient Safety Agency N.P.S.A.
Patient Safety Alert Correct Site Surgery.
Website: www.npsa.nhs.uk/easysiteweb/getresource.axd.june2014.pdf
• Guide to Surgical Site Marking High 5s
Website:
www.has-sante.fr/portal/upload/docs/application/pdf/2013guidetosur
gicalsitemarking.pdf