Reusing surgical instruments during Mohs micrographic surgery: safe from infection, but not free from risk.
We report several scenarios of compromise in patient safety owing to the re-use of mis-assigned patient's surgical instruments in Mohs micrographic surgery.We discuss the breaks in universal protocols that others may experience in their practices and describe corrective measures that our institutions employed to avoid such future events.There is a lack of publication in the literature on the topic of mis-assigned instrument use in Mohs surgery. We believe that the  practice of re-using instruments is cost-effective and therefore common. Based on our humbling experience, this publication may initiate important discussion among dermatologist regarding safety protocols at their respective institutions.
Tatyana A
TA
Petukhova
Thomas H
TH
King
Kenny J
KJ
Omlin
Department of Dermatology, University of California, Davis, Sacramento, CA. dbeisen@ucdavis.edu.
Daniel B
DB
Eisen
D003428:Cross Infection / Q000517:prevention & control*; D017743:Equipment Reuse; D006801:Humans; D015580:Mohs Surgery / Q000295:instrumentation*; D012878:Skin Neoplasms / Q000601:surgery*; D013525:Surgical Instruments; D000067494:Time Out, Healthcare / Q000379:methods*