Experience of wrong site surgery and surgical marking practices among clinicians in the UK.
BACKGROUND
Little is known about the incidence of "wrong site surgery", but the consequences of this type of medical error can be severe. Guidance from both the USA and more recently the UK has highlighted the importance of preventing error by marking patients before surgery.


OBJECTIVE
To investigate the experiences of wrong site surgery and current marking practices among clinicians in the UK before the release of a national Correct Site Surgery Alert.


METHODS
38 telephone or face-to-face interviews were conducted with consultant surgeons in ophthalmology, orthopaedics and urology in 14 National Health Service hospitals in the UK. The interviews were coded and analysed thematically using the software package QSR Nud*ist 6.


RESULTS
Most surgeons had experience of wrong site surgery, but there was no clear pattern of underlying causes. Marking practices varied considerably. Surgeons were divided on the value of marking and varied in their practices. Orthopaedic surgeons reported that they marked before surgery; however, some urologists and ophthalmologists reported that they did not. There seemed to be no formal hospital policies in place specifically relating to wrong site surgery, and there were problems associated with implementing a system of marking in some cases. The methods used to mark patients also varied. Some surgeons believed that marking was a limited method of preventing wrong site surgery and may even increase the risk of wrong site surgery.


CONCLUSIONS
Marking practices are variable and marking is not always used. Introducing standard guidance on marking may reduce the overall risk of wrong site surgery, especially as clinicians work at different hospital sites. However, the more specific needs of people and specialties must also be considered.
Giles
Sally J
SJ
University of Liverpool, Stepping Hill Hospital, Stockport, UK. sjgiles@liverpool.ac.uk
Rhodes
Penny
P
Clements
Gill
G
Cook
Gary A
GA
Hayton
Ruth
R
Maxwell
Melanie J
MJ
Sheldon
Trevor A
TA
Wright
John
J
D006779:Hospitals, Public; D006801:Humans; D015994:Incidence; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D011939:Mental Recall; D013508:Ophthalmologic Surgical Procedures / Q000009:adverse effects* / Q000592:standards; D016134:Organizational Policy; D019637:Orthopedic Procedures / Q000009:adverse effects* / Q000592:standards; D010355:Patient Identification Systems; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000009:adverse effects / Q000379:methods*; D017751:Safety Management / Q000379:methods*; D013222:State Medicine / Q000592:standards; D011795:Surveys and Questionnaires; D006113:United Kingdom / Q000453:epidemiology; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000592:standards; D014956:Writing