title: Experience of wrong site surgery and surgical marking practices among clinicians in the UK.
abstract: 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.
authors.affiliation: University of Liverpool, Stepping Hill Hospital, Stockport, UK. sjgiles@liverpool.ac.uk
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Giles
authors.forename: Penny
authors.initials: P
authors.lastname: Rhodes
authors.forename: Gill
authors.initials: G
authors.lastname: Clements
authors.forename: Gary A
authors.initials: GA
authors.lastname: Cook
authors.forename: Ruth
authors.initials: R
authors.lastname: Hayton
authors.forename: Melanie J
authors.initials: MJ
authors.lastname: Maxwell
authors.forename: Trevor A
authors.initials: TA
authors.lastname: Sheldon
authors.forename: John
authors.initials: J
authors.lastname: Wright
mesh_terms: 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