X marks the spot… not

Remember the episode from “ER” during which the abrasive Dr. Robert “Rocky” Romano was preparing to have surgery on his arm? He tells his colleague, Dr. Elizabeth Corday, “Do me a favor. Write, ‘Not this one, idiot’ on  my right arm. Oh, like it doesn’t happen!”

When wrong-site surgery becomes one of the staples of popular culture, you know the public awareness is high.

But not so fast, Dr. Romano. Although it’s generally assumed that patients ought to be engaged in helping to mark the surgical site, a new study suggests, rather surprisingly, that this assumption is faulty. The study was recently published online in the Journal of Patient Safety.

Two hundred patients scheduled to undergo orthopedic surgery were asked to mark their own surgical site ahead of time with the word “yes.” The majority, 68.2 percent, did so correctly – but 32 percent simply didn’t follow through.

Factors such as gender, education level, occupation and history of depression, which often can influence patients’ health behaviors, did not appear to make a difference, the study’s authors found.

A few of the other findings offer some clues, though. Patients who marked the site were slightly younger and more likely to speak English as their primary language than those who didn’t. The time between when they enrolled in the study and when they actually had their surgery also seemed to be predictive. Those who marked the site were enrolled in the study an average of 10.4 days before their surgery. For those who didn’t, it was 23.1 days, suggesting that timeliness might be important in getting patients more engaged in the process.

Significantly, none of the patients who marked their own site made an error, nor did they make any extra marks that could contribute to a wrong-site surgery. The real issue, the study’s authors conclude, seems to lie with motivating patients to participate in the first place. In view of the fact that more than three out of 10 patients in the study failed to mark the site as they were asked to, “patient involvement in surgical site marking is unreliable and may not help in decreasing the chances of wrong-site surgery,” they wrote.

These findings aren’t much different from a similar study done in 2003. In this case, the researchers followed 100 patients at a private foot and ankle practice who underwent elective orthopedic surgery. Fifty-nine of them marked the site correctly, 37 didn’t mark the site at all, and four marked the site but didn’t follow directions for how to correctly do so.

The authors offer a possible explanation: “This behavior suggests that patients expect the system to ‘take care of everything,’ despite solicitation of their active participation to avoid such adverse events.”

Avoiding wrong-site surgery seems like it would be easy. Those who study the process, however, are finding that it’s not. Often it’s the little things that create ambiguity. Should the correct site be marked with an X? Best practices now recommend against this, since an X can be interpreted in opposite ways: as “X marks the spot” or as “not this site.” Many clinicians now even make a point of using the word “correct” instead of “right,” to avoid confusion between right and left.

Although patients can be tempted to mark the site on their own, and perhaps add the warning “not here!” for good measure, many experts don’t think this is a good idea. For one thing, it bypasses the surgeon who’s doing the actual cutting. For another, once the patient is in the OR and prepped for surgery, these markings can be obscured by surgical drapes or blurred or dissolved by prep solutions, and lead to potentially disastrous confusion. For some of the same reasons, it’s not always preferable to have the site marked a week or two in advance of the surgery and risk having the mark rub off.

The recommendation that’s currently considered the gold standard is to have the surgeon, preferably with the involvement of the patient, sign the site with the surgeon’s initials. It’s all a work in progress, however, and it seems we still have much to learn about the best role for patients in making the process of marking the correct surgical site more consistently safe.

West Central Tribune photo by Ron Adams

One thought on “X marks the spot… not

  1. Pingback: The weekly rundown, Nov. 24 | HealthBeat

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