This paper aims at the analysis on best practices for surgical site marking among patients during preoperative conditions to reduce wrong site surgeries. The incidence of wrong site surgery is observed to be escalated annually among world population. According to Simons et al (2009) stresses that only 48% of surgeons regularly mark their surgical sites. Surgical confusions are one of the poorly studied clinical research areas. Wrong site surgery is defined by (Mulloy 2008) as surgery conducted in wrong body parts, wrong organs or wrong surgical procedure performed. Surgical training and practising includes the both technical and non-technical skills. Most of the surgical errors are caused due to human factors which accounts for non-technical errors. Human factors such as lack of situation awareness, poor decision making, lack of communication and team work accounts up for the non-technical errors during surgery. Due to the raising rates of wrong site surgeries and its associated fatalities and medical complications, the research intent was based in search of best methods for surgical site making since medical errors during surgery accounts for 8% of annual death in UK and fatalities due to surgical errors are forecasted to escalate in future. According to (Joint Commission 2015a), there are generally the three important segments in UP such as pre-strategy check, site stamping, and a period out. From 2006, each recovering center, walking thought working environments, and office-based surgery exercises sanction by the Joint Commission are obliged to utilize the UP and all assurance workplaces oblige adherence to the UP for reimbursement. From 2015, the CMS insisted that everyhospitals, clinics and nursing homes should have good surgical systems to offer a safe surgery agenda with a specific end goal to get repayment. Despite of having such universal regulations, the incidence of wrong site surgery keep on increasing.
Colon, rectal and ostomy surgeons regularly mark the surgical sites to reduce the wrong site surgeries. This study employs qualitative research design using secondary research methods. Practise based extended critical review of literature was chosen as the research design. The ultimate reason for selection of this model is to identify the best methods for surgical site marking from the available medical literature and to critically review which method is widely used in current medical practise. Growing source of information available in the form of electronic records and medical research databases have reduced the pain of researchers and healthcare practitioners for identification and selection of ideal method which is retrieved effectively at reduced cost of time and money. This study is conducted as a preliminary research to observe the best method for surgical site marking practise to prevent the wrong site surgery. A systematic review using PICO model was used in this study to analyse the best practices in the surgical site marking. Journals were extracted from medical research literature databases such as COCHRANE, EMBASE, PUBMED, PUBMED CENTRAL and MEDLINE. Out of 15 articles retrieved only 10 met the inclusion criteria of the study. Most of the journals have addressed that bio absorbable tissue marking system with additional imaging studies increase the effectiveness of surgical site marking practices to reduce the wrong site surgery. The study concludes that CT scan guided hook wire positioning or marking method was observed to have increased safety, efficacy, speed and reliability for localisation of surgical sites. This study reflects the ability of understanding and interpreting the research literature on surgical site marking methods. In specific, this has influenced the personal skills and capabilities to critically analyse and identify the best practices for surgical site marking in current medical practice to gain insight over nursing practice. This critical review has paved way for present and future research implications for conducting practical evidence based research studies for the development of best practices in surgical site marking to facilitate the surgeons and patients.
Systematic review of literature
Overview about Wrong Site Surgery
Lack of communication is the main blunder adding to WSS. In an orderly audit,
Hempel et al (2013) distinguished 125 experimental studies and four clinical practice rules
distributed from 2004 through 2013 that reported reasons for WSS. Their examination
uncovered that essential underlying drivers of wrong-site surgery were because of 1)
correspondence issues, for example, mistaken data and misperceptions of data, 2) not taking
after arrangements, 3) not performing wellbeing strategies in an important manner, 4)
deficient approaches, and 5) the absence of procedural institutionalization added to WSS
occasions. As a result of this proof blend, the scientists prescribed that an institutionalized
convention to forestall WSS be produced though wellbeing couldn't care small clinics
directing surgeries.
By 2005, communication was cited as the major cause of WSS accounting for 70% of
WSS, followed by “deficits of procedural compliance (64%), leadership (46%), competency
and credentialing (29%), availability of information (28%), organizational culture (23%),
orientation and training (20%), patient assessment (18%), care planning (17%), staffing
(10%), environmental safety/security (10%), and continuum of care (5%)” (Joint
Commission, 2013, p. 5).Mulloy (2008) discovered comparable results when inspecting the
viability of the 'AORN Right Site Surgery Toolbox' and the UP among 519 enlisted medical
attendants and 325 non-enrolled medical caretaker surgical expert respondents. An
underlying driver investigation of WSS was directed and uncovered three repeating
correspondence hazard circumstances: 1) correspondence disappointments with the patient
and among individuals from the surgical group, 2) correspondence disappointments amid the
preoperative appraisal of the patient, and 3) correspondence disappointments when checking
the right agent site. Mulloy (2008) found that 91% of enlisted medical caretakers and 73% of
non-enrolled attendant - surgical professionals reported the AORN toolbox was useful. Dunn
(2006) examined 455 WSS records and observed that in 80% of the cases, insufficient
correspondence was the underlying driver of the occasion. Stahel et al. (2010) found that out
of 27,370 self-reported antagonistic events, 85% of WSS occasions were because of lapses in
judgment while 72% were because of inability to perform a surgical 'time-out' preceding cut.
Surgical blunders take a mixed bag of structures.
From DeVine et al., (2010) systematic review of 433,528 spinal surgical cases in
Pennsylvania to focus the occurrence of surgical slips. There were 427 occurrences of WSS
with 70% identified with wrong-side surgeries, 56% to 'close misses', 14% to wrong
area/level surgeries, 9% to wrong systems, and 8% to the wrong patient. The discoveries
demonstrated that WSS is the consequence of breakdowns in correspondence identified with
erroneous surgical site confirmation and off base correspondence between the surgical group.
It additionally demonstrated that WSS came about because of inability to confirm
understanding data preceding surgery. The clinical proposals of this precise survey
recommend that the Joint's utilization Bonus alone is lacking to anticipate WSS. From this
survey, the clinical proposals place that notwithstanding the Joint Commission there are
intraoperative pictures taken after the surgical site is imagined. Preoperative pictures are then
contrasted with these pictures in the space to guarantee the right level of spinal surgery.
Impact of wrong site surgery
Wrong-site surgery is a possibly annihilating circumstance for both the patient and
specialist (Robinson et al 2009). It however keep on being a worry especially in orthopedics,
in spite of real activities to address the issue, for instance the "work through your initials"
battle by the Canadian Orthopedic Affiliation, the "sign your site" activity by the AAOS, the
"SMaX" activity and the Imperial School of Specialists' and NPSA direction. By February
2010, all doctor's facilities in the UK ought to have actualized utilization of the agenda (PSF
2015). In any case, consequences of an overview show that more than 60% of units were
assessing or inspecting whether the agenda had any kind of effect by AAOS (2009). Just 29%
of clinics found had distinguished an approach to record the agenda was utilized and having
an effect (NPSA 2013). An absence of vigorous confirmation advancing the agenda's
utilization, briefings and debriefings can never again be refered to as a purpose behind
moderate appropriation of this activity.
In a recent study conducted by deVries EN et al (2012) uncover that huge decreases in
surgical mortality and horribleness can be made through utilization of agendas. The main
drivers of wrong-site surgery are multi factorial. Be that as it may, highlighting unmistakably
in an investigations' portion incorporate breakdown in correspondence between surgical
colleagues, nonattendance of confirmation in the operation room and of a confirmation
agenda, off base stamping or assent, readiness of the wrong side, inaccurate hanging, patient
offering an explanation to the wrong name and disappointment of a formal 'time-out' system.
In an examination of wrong - site surgery close misses and genuine events, evaluations in
which close misses were recognized that did not advance on to real wrong-site events were
altogether more inclined to report consistence with exercises, for example, quiet ID,
preoperative compromise conventions, documentation of surgical site on assent structure,
support of the specialist in preoperative confirmation and cooperation of all surgical
colleagues in formal time-out systems.
PICO analysis on best practices in surgical site marking
This review throws on systematic overview for identification of best practices in
surgical site marking from the literature using PICO model.
1. Thakar&Mearse (2012)
In a prospective randomised clinical study conducted by Thakkar and Mearse (2012)
have reported that it is very crucial to employ surgical marking to reduce wrong site surgery.
In this study, two different kind of solutions were used namely chlorhexidine based and other
one is iodine based in skin preparations. The study employed both qualitative and quantitative
research approaches to observe the best solution that provides visibility to the surgeons. The
study recruited twenty patients and ten surgeons for assessing the visibility of the marked
site. Results from statistical data clearly remarked that chlorhexidine based solutions used for
surgical site marking was highly visible to the surgeons rather than iodine based site
markings. The study finally concluded that iodine based solutions used for surgical site
marking can reduce the wrong site surgery by increasing the visibility to the surgeons.
2. Person et al (2012)
In a systematic survey study conducted by Person and his colleagues (2012) on
analysing the impact of stomal site marking in pre-operative conditions on 105 participants
using quality of life survey questionnaires observed that stoma site marking procedure has
been observed to reduce the wrong site surgery, enhancing their autonomy and also reduces
the rate of clinical complications in patients during post-operative conditions. This study
employs quantitative research design to assess the survey responses. Data gathered through
survey responses are analysed statistically through chi squared test with significance p<0.05.
3. Colwell and Gray (2007)
In a systematic review analysis conducted by Colwell and Gray (2007) have reported
that a wide range of potential risk factors such as age, comorbidity status, smoking, suture
choice affects the preoperative complications. Upon analysing the six articles, authors
concluded that reduced number of evidences suggest that stomal marking has decreased the
preoperative conditions.
4. Shah et al (2011)
In a survey study conducted by Shah and his colleagues (2011) analysed the surgical site
marking and surgical timed out procedures. The study employed quantitative research design
with open ended survey questionnaire among chief paediatric surgeons and operation theatre
heads. The survey results are analysed using Chi squared test. 84% of the chief surgeons are
satisfied with surgical site marking procedures for nasal surgery and endoscopy.
5. Harman and Benjamin (2013)
In a prospective study conducted by Harman and Benjamin (2013) have emphasised
the effectiveness of new method in surgical cavity using bio absorbable 3 dimensional tissue
marker. This study employs quantitative research method to estimate the effectiveness of bio
absorbable tissue marker namely BioZorb TM implanted during lumpectomy among patient
populations. The current study stresses that preoperative imaging studies such as X-ray,
mammography, CT-scans and magnetic resonance imaging (MRI scans) shall assist the bio
absorbable tissue marker in surgical site marking process. In this study, 16 participants were
selected. These tissue markers are classified into two types namely marker made up of
titanium and PLA. The selected patients who undergo lumpectomy had imaging studies such
as mammogram, MRI and CT scans and followed by the implantation of tissue markers prior
to lumpectomy. The results suggest that tissue markers easily absorbed with the tumours and
clearly delineated the margins of the malignant tumours.
6. Mears et al (2009)
The main aim of this study is to analyse the withstanding capacity of solution
preparations in surgical site marking. Frequently, chlorhexidine based solutions and iodine
solutions are used for surgical site marking. Site marking preparation that withstands large
period requires additional scrubbing. In this study, 5 types of cadaveric skin flaps were
employed. Each sample was marked with two rows with nine various types of skin markers.
One of skin markings was treated with chlorhexidine based skin marking preparations and
other row was treated with the iodine based solution. Using imaging software, the digital
photograph of skin flaps including snaps taken before and after the site marking was assessed
for greyscale region. The variations in the greyscale region contrast were statistically
evaluated using multiple regression analysis method using SPSS and significance of p<0.05
was estimated for difference in greyscale contrast among rows and markings in skin flaps.
The study followed standard procedures for surgical site marking. Nine different type
of skin markers such as Sandel 4-in-1 marker (skin, wide) (Sandel Medical Industries, LLC,
Chatsworth, Calif); (2) Waterproof Permanent Marker-Mini, Fine Tip (Viscot Medical LLC,
East Hanover, NJ); (3) OP-marks mini markers (OP-marks, Inc, Bogart, Ga); (4) OP-marks
mini max (OP-marks, Inc); (5) Accu-line wide body (Accu-line Products, Inc, Hyannis,
Mass); (6) Sharpie super permanent marker (Sanford Corporation, Oak Brook, Ill); (7)
Securline surgical skin marker no. 1000 (Precision Dynamics Corporation, San Fernando,
Calif); (8) HMS Twin-Tip broad (Hospital Marketing Services Co, Inc, Naugatuck, Conn);
and (9) HMS Twin-Tip fine (Hospital Marketing Services Co, Inc). A single line mark 50mm
long was made in every row using nine different skin marker pens.
After marking, each skin flaps are photographed using digital camera with 10.1
megapixel camera and 100 mm macro lens of Canon camera, USA. The important camera
settings include the speed of shutter 1/60 seconds and F stop value as 4.0. These images are
analysed for greyscale contrast regions using Adobe Photoshop CS2. Using this software, the
images are converted into 256 grayscale levels. The differences between the grayscale
regions before and after the marking are assessed using statistical software STATA 10
developed by STATACORP. The results clearly depicts that chlorhexidine based solutions
has less grayscale regions than iodine based solutions and concludes strongly that iodine
based solutions has high grayscale regions than chlorhexidine and additionally marking sites
treated with chlorhexidine erased soon than iodine. The main limitations of this study are the
present study employed cadaveric skins than live skin; no literature evidence exists for
different reactivity over the various kinds of markers. All specimens in this study has
exhibited light discolouration. Dark pigmentation is expected among one of the solutions
used for the site marking
7. Bergal et al (2011)
Bergal et al (2011) has conducted a nonrandomised clinical trial among 200
participants to evaluate the willingness of patients to undertake surgical site marking. 200
patients undergoing orthopaedic surgery are recruited in this study. Participant’s data such as
age, gender, type of the procedure and history of previous type of orthopaedic surgeries and
smoking status of patients. The study results displays that mean age of the patients is 48 and
time lapse between surgical site marking enrolment and surgery. The main results conclude
that there was no significant relationship between patients involvement in surgical site
marking which is regarded as unreliable. Authors finally concluded that patient’s
demographic variables are entirely unrelated with the demographical variables such as age,
gender, income, smoking status etc.
8. Suzuki et al (2014)
The chief aim of the research investigation conducted by Suzuki and his colleagues
(2014) evaluated the clinical and technical efficacy of CT-guided hook wire marking for
conducting video assisted thoracic surgeries to remove pulmonary lesions. The current study
is designed as quantitative experimental research design and employed 154 patients
undergoing thoracic surgery as participants. The study population encompasses 75 men and
79 women with the median age as 62 years. The age groups of participant population range
from 23 to 89 years. The study assesses both technical and clinical efficacy based on medical
records, imaging studies, surgical success rate and finally postoperative surgical
complications. The study defines accomplishment of technical success as successful hook
wire marking on pulmonary lesions without dropping the marker before video assisted
thoracic surgery and surgical success rate was achieved by negative surgical margins upon
pathological examination after VATS among patients. The study finally concludes that CT
hook wire marking achieved 97.5% of technical success and surgical success was reported as
98% with 158 /161 surgeries.
9. Hoang (2012)
In a study conducted by Hoang (2012) has analysed the efficacy of CT guided hook
wire marking in detecting non palpable cervical lymph nodes. Authors describe that PET/CT
imaging studies greatly assists in detecting the metastasis among cancer patients. Non
palpable lesions from breast tissues are easily detectable using imaging studies and so site
marking performed using the assistance of imaging techniques largely help for the co-
localization of tumours or lumps during surgeries. This study has utilised non randomised
clinical trial using three subjects. Three patients each suffering from different type of
carcinoma are recruited in this study. Patient A was suffering from adenoid cyst carcinoma in
T2a stage, Patient B possess medical history of large B cell carcinoma and patient C is
suffering from high grade ovarian carcinoma in stage III c. All three study participants were
observed to be female with age ranging from 58 to 65 years with mean age as 61 years. All
patients received chemo and radiation therapy previously. Hook wire marking to remove
lesions are successfully performed for all patients. Mean intervention time taken for this
procedure is 9 minutes with the mean operation time of 75 minutes for each patient. Surgeons
do not report any mistakes during surgical resections such as wrong delineation of lesion
margins before surgery. The study also looked for postoperative complications among the
patients. Pathological findings reported that patient A had no lesions in lymph nodes, patient
B had follicular hyperplasia without the clinical features of lymphoma and finally Patient C
had metastatic carcinoma sharing similar morphology of ovarian carcinoma. The study finally
concludes that hook wire marking using CT/PET imaging techniques efficiently localises the
lesions and tumours before surgery and assists the surgeons. Also, the post-operative
complications were seemed to be less among patients.
10. Li et al (2014)
Li and his colleagues (2014) has analysed the effectiveness of hook wire positioning
method before the thoracoscopic surgery. This study employs 84 patients who undergo
thoracoscopic wedge resection from the period of January to December 2013. Study
participants were grouped into two classes. Bunch A comprised of 38 situations where the
snare wire situating method was not utilized, and the situating methodologies were
intraoperative perception and palpation. Class B comprised of 46 situations where the snare
wire situating method was used.The distance across of every knob was under 2 cm, what not
patients experienced the operation inside of 2 h of obtrusive situating. The assessment files
included situating achievement rate, situating related difficulties, and rate of transformation
to thoracotomy. In Class A, nine patients (23.68%) experienced transformation to
thoracotomy; in Class B, three patients (6.52%) did. This distinction was factually critical (P
< 0.05). The normal operation span was 118 ± 21 min in Gathering and 53 ± 18 min in
Gathering B. The distinction between both gatherings was factually huge (P < 0.05). The
normal length of healing center stay of patients who experienced transformation to
thoracotomy was 8.7 ± 2.2 days, and of patients who experienced thoracoscopic pneumonic
wedge resection was 4.5 ± 1.6 days. This distinction was measurably critical (P < 0.05).
Authors finally conclude that results from quantitative analysis emphasises that CT scan
guided hook wire marking method effectively localises the pulmonary nodules during
preoperative thoracoscopic surgery. Besides helping in the co-localisation of pulmonary
nodules, it also effectively lessens the rate of conversion to thoracotomy, and minimises the
time taken for the thoracoscopic surgery.