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In Patient Safety Alert 6, The National Patient Safety Agency (NPSA) stated that “across the NHS, there is no single standard method for marking a surgical site, which increases the likelihood of confusion and error. Despite high professional standards and excellent best practice at a local level, safety can be improved by using a consistent national standard for pre‐operative marking and a verification checklist”.1
The deadline for consideration/implementation of these NPSA guidelines (or a robust local alternative) was 16 March 2005. We attempted to ascertain to what extent standardisation in preoperative marking exists within ophthalmology by surveying a sample of UK consultant ophthalmologists in March 2006.
Questionnaires were sent to consultants in randomly chosen geographical regions. The first part of the questionnaire asked how frequently patients were marked for each operation from a list of common eye procedures. The second part asked which methods were used to identify and confirm patient, procedure and site before surgery. The final section asked for common reasons for not marking patients. Replies were anonymous.
We obtained 145 replies from 205 questionnaires (response rate 71%). For cataract surgery, 99 (76%) respondents always marked patients and 26 (20%) rarely or never did. Marking was more likely for eye removal (probably because of the severe consequences of wrong site surgery) and for patients undergoing general anaesthesia (probably based on the perception that wrong site surgery is more likely without direct involvement by patients). The lowest rates were for minor procedures and lasers, maybe because of a lower perceived risk of the incidence and consequences of wrong site surgery. However, theoretically, errors in these procedures too could have serious consequences—for example, retinal laser to the wrong eye. It may be the role of the regulatory bodies to decide which procedures should and should not be marked.
When confirming details preoperatively, most surgeons stated that they checked the notes (87% of those surveyed), verbally confirmed with the patient (86%) and consulted the consent form before starting the surgery (75%). Fewer surgeons checked the patient's identification band or relied on the operating list or handover from other staff. There was variability between respondents with regard to the number and types of checks, although nearly all either always marked patients themselves or satisfied themselves otherwise that details were correct before starting surgery (and took pains to make this clear on the questionnaire).
The most common reasons for not marking patients were that the patient gave “verbal confirmation”, or that “the pathology was obvious”. Seven respondents thought that preceding checks were adequate (“there are 3 checks by nurses and 2 by medical staff”) and six did not believe in marking patients (“marks rub off”, “false sense of security”, “mark is anonymised—a patient has been known to reapply a mark in the mirror to the wrong side”.
Generally, the survey suggests a degree of variability in marking and preoperative checking. The variability between different units could be due to local “robust systems”, but this is less likely when one looks at the variability within each unit.
Although wrong site surgery is uncommon, it does happen, and consequences may range from minimal to devastating.2 These errors are thought to be entirely preventable. Marking all patients will not eliminate this risk—there is always scope for human error. However, it seems logical that standardisation of preoperative marking and checking as suggested by the NPSA would reduce the occurrence of this complication. For a practitioner to know that whichever specialty, region or trust they are working in, the same systems are employed, should reduce at least one avenue of potential error.