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 SS  Vol.6 No.7 , July 2015
Errors in Surgical Site Identification during Cutaneous Surgery for Skin Cancer: Review and Recommendations
Abstract: Surgical error due to incorrect identification of the surgical site has been known to occur right from the beginning of surgical practice through the ages. However, increasing awareness, preventative efforts and risks of litigation have not eliminated this problem. Cutaneous surgery for skin cancer makes up a large proportion of procedures performed each year and it is often difficult to correctly identify biopsy sites, especially as this is not easy in sun-damaged skin. In this review article, we review the incidence of wrong-site surgery, measures taken by professional bodies, and the use of photography and newer technologies in an attempt to eliminate this distressing event in the field of plastic and dermatologic surgery. The purpose of this review is to highlight the incidence of such surgical site identification errors, evaluate the risk factors, and educate the surgeon about measures that can be undertaken to avoid being faced with such a situation.
Cite this paper: Paul, S. , (2015) Errors in Surgical Site Identification during Cutaneous Surgery for Skin Cancer: Review and Recommendations. Surgical Science, 6, 327-335. doi: 10.4236/ss.2015.67049.
References

[1]   Rogers, H.W., Weinstock, M.A., Harris, A.R., Hinckley, A.R., et al. (2010) Incidence Estimate of Non-Melanoma Skin Cancer in the United States, 2006. Archives of Dermatology, 146, 283-287.
http://dx.doi.org/10.1001/archdermatol.2010.19

[2]   McGinness, J.L. and Goldstein, G. (2010) The Value of Preoperative Biopsy-Site Photography for Identifying Cutaneous Lesions. Dermatologic Surgery, 36, 194-197.
http://dx.doi.org/10.1111/j.1524-4725.2009.01426.x

[3]   Ke, M., Moul, D., Camouse, M., Avram, M., et al. (2010) Where Is It? The Utility of Biopsy-Site Photography. Dermatologic Surgery, 36, 198-202.
http://dx.doi.org/10.1111/j.1524-4725.2009.01425.x

[4]   Campbell, R.M., Perlis, C.S., Malik, M.K. and Dufresne Jr., R.G. (2007) Characteristics of Mohs Practices in the United States: A Recall Survey of ACMS Surgeons. Dermatologic Surgery, 33, 1413-1418.
http://dx.doi.org/10.1097/00042728-200712000-00001

[5]   Perlis, C.S., Campbell, R.M., Perlis, R.H., Malik, M., et al. (2006) Incidence of and Risk Factors for Medical Malpractice Lawsuits among Mohs Surgeons. Dermatologic Surgery, 32, 79-83.
http://dx.doi.org/10.1097/00042728-200601000-00016

[6]   Clarke, J.R., Johnston, J., Blanco, M. and Martindell, D.P. (2008) Wrong-Site Surgery: Can We Prevent It? AdvSurg, 42, 13-31.

[7]   James, M.A., Gray, J., Iii, S., Harrast, J.J., Emery, S.E. and Hurwitz, S. (2012) The Occurrence of Wrong-Site Surgery Self-Reported by Candidates for Certification by the American Board of Orthopaedic Surgery. Journal of Bone and Joint Surgery, 94, e2(1-12).

[8]   State of New York Department of Health (2008) The New York Patient Occurrence and Tracking System (NYPORTS).
http://www.health.ny.gov/facilities/hospital/nyports/index.htm.

[9]   Gallagher, T.H. (2009) A 62-Year-Old Woman with Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error. The Journal of the American Medical Association, 302, 669-677.
http://dx.doi.org/10.1001/jama.2009.1011

[10]   The Joint Commission (2001) A Follow-Up Review of Wrong Site Surgery. Sentinel Event Alert.
http://www.jointcommission.org/assets/1/18/SEA_24.pdf.

[11]   Handley, W.S. (1907) The Pathology of Melanotic Growths in Relation to Their Operative Treatment. The Lancet, 1, 927-933, 996-1003.

[12]   Stehlin, J.S. and Clark, R.L. (1965) Melanoma of the Extremities. The American Journal of Surgery, 110, 366-383.
http://dx.doi.org/10.1016/0002-9610(65)90076-0

[13]   Cochran, A.J. (1971) Studies of the Melanocytes of the Epidermis Adjacent to Tumors. Journal of Investigative Dermatology, 57, 38-43.
http://dx.doi.org/10.1111/1523-1747.ep12292060

[14]   Wong, C.K. (1970) A Study of Melanocytes in the Normal Skin Surrounding Malignant Melanomata. Dermatologica, 141,215-225.
http://dx.doi.org/10.1159/000252469

[15]   Olsen, G. (1966) The Malignant Melanoma of the Skin: New Theories Based on a Study of 500 Cases. Acta Chirurgica Scandinavica, Supplementum, 365, 1-220.

[16]   Elias, E.G., Didolker, M.S., Goel, I.P., et al. (1977) A clinic-Pathologic Study of Prognosis Factors in Cutaneous Malignant Melanoma. Surgery, Gynecology & Obstetrics, 144, 327-334.

[17]   Breslow, A. and Macht, S.D. (1977) Optimal Size of Resection Margin for Thin Cutaneous Melanomas. Surgery, Gynecology & Obstetrics, 145, 691-692.

[18]   Jemal, A., Siegel, R., Xu, J., et al. (2010) Cancer Statistics, 2010. CA: A Cancer Journal for Clinicians, 60, 277-300.
http://dx.doi.org/10.3322/caac.20073

[19]   (1993) National Institutes of Health Consensus Development Conference Statement on Diagnosis and Treatment of Early Melanoma, January 27-29, 1992. The American Journal of Dermatopathology, 15, 34-43; Discussion 46-51.
http://dx.doi.org/10.1097/00000372-199302000-00006

[20]   Balch, C.M., Urist, M.M., Karakousis, C.P., et al. (1993) Efficacy of 2-cm Surgical Margins for Intermediate-Thickness Melanomas (1 to 4 mm). Results of a Multi-Institutional Randomized Surgical Trial. Annals of Surgery, 218, 262-267; Discussion 267-269.
http://dx.doi.org/10.1097/00000658-199309000-00005

[21]   Bumsted, R.M., Panje, W.R. and Ceilley, R.I. (1983) Delayed Skin Grafting in Facial Reconstruction. When to Use and How to Do. Archives of Otolaryngology, 109, 178-184.
http://dx.doi.org/10.1001/archotol.1983.00800170044012

[22]   Balch, C.M., Soong, S.J., Smith, T., et al. (2001) Long-Term Results of A Prospective Surgical Trial Comparing 2 cm vs. 4 cm Excision Margins for 740 Patients with 1 - 4 mm Melanomas. Annals of Surgical Oncology, 8, 101-108.
http://dx.doi.org/10.1007/s10434-001-0101-x

[23]   Khayat, D., Rixe, O., Martin, G., et al. (2003) Surgical Margins in Cutaneous Melanoma (2 cm versus 5 cm for Lesions Measuring Less than 2.1-mm Thick). Cancer, 97, 1941-1946.
http://dx.doi.org/10.1002/cncr.11272

[24]   Ringborg, U., Andersson, R., Eldh, J., et al. (1996) Resection Margins of 2 versus 5 cm for Cutaneous Malignant Melanoma with a Tumor Thickness of 0.8 to 2.0 mm: Randomized Study by the Swedish Melanoma Study Group. Cancer, 77, 1809-1814.
http://dx.doi.org/10.1002/(SICI)1097-0142(19960501)77:9<1809::AID-CNCR8>3.0.CO;2-6

[25]   Veronesi, U., Cascinelli, N., Adamus, J., et al. (1988) Thin Stage I Primary Cutaneous Malignant Melanoma. Comparison of Excision with Margins of 1 or 3 cm. The New England Journal of Medicine, 318, 1159-1162.
http://dx.doi.org/10.1056/NEJM198805053181804

[26]   Thomas, J.M., Newton-Bishop, J., A’Hern, R., et al. (2004) Excision Margins in High-Risk Malignant Melanoma. The New England Journal of Medicine, 350, 757-766.
http://dx.doi.org/10.1056/NEJMoa030681

[27]   Haigh, P.I., DiFronzo, L.A. and McCready, D.R. (2003) Optimal Excision Margins for Primary Cutaneous Melanoma: A Systematic Review and Meta-Analysis. Canadian Journal of Surgery, 46, 419-426.

[28]   Lens, M.B., Nathan, P. and Bataille, V. (2007) Excision Margins for Primary Cutaneous Melanoma: Updated Pooled Analysis of Randomized Controlled Trials. Archives of Surgery, 142, 885-891.
http://dx.doi.org/10.1001/archsurg.142.9.885

[29]   Sladden, M.J., Balch, C., Barzilai, D.A., et al. (2009) Surgical Excision Margins for Primary Cutaneous Melanoma. Cochrane Database of Systematic Reviews, No. 4, Article No. CD004835.
http://dx.doi.org/10.1002/14651858.cd004835.pub2

[30]   Traquair, H. (1947) Removal of the Wrong Eye. British Journal of Ophthalmology, 31, 8-12.

[31]   Gibbs, V.C. (2005) Patient Safety Practices in the Operating Room: Correct-Site Surgery and Nothing Left Behind. The Surgical Clinics of North America, 85, 1307-1319.

[32]   Makary, M.A., Mukherjee, A., Sexton, J.B., et al. (2007) Operating Room Briefings and Wrong-Site Surgery. Journal of the American College of Surgeons, 204, 236-243.
http://dx.doi.org/10.1016/j.jamcollsurg.2006.10.018

[33]   Backster, A., Teo, A., Swift, M., et al. (2007) Transforming the Surgical “Time-Out” into a Comprehensive “Preparatory Pause”. Journal of Cardiac Surgery, 22, 410-416.
http://dx.doi.org/10.1111/j.1540-8191.2007.00435.x

[34]   Clarke, J.R., Johnston, J. and Finley, E.D. (2007) Getting Surgery Right. Annals of Surgery, 246, 395-403.
http://dx.doi.org/10.1097/SLA.0b013e3181469987

[35]   Ring, D.C., Herndon, J.H. and Meyer, G.S. (2010) Case 34-2010: A 65-Year-Old Woman with an Incorrect Operation on the Left Hand. The New England Journal of Medicine, 363, 1950-1957.
http://dx.doi.org/10.1056/NEJMcpc1007085

[36]   The Joint Commission Center for Transforming Healthcare. Reducing the Risk of Wrong Site Surgery (accessed 30 May 2015).
http://www.centerfortransforminghealthcare.org/UserFiles/file/CTH_WSS_Storyboard_final_2011.pdf.

[37]   DeVine, J., Chutkan, N., Norvell, D.C. and Dettori, J.R. (2010) Avoiding Wrong Site Surgery: A Systematic Review. Spine, 35, S28-S36.
http://dx.doi.org/10.1097/BRS.0b013e3181d833ac

[38]   Mehtsun, W.T., Ibrahim, A.M., Diener-West, M., Pronovost, P.J. and Makary, M.A. (2013) Surgical Never Events in the United States. Surgery, 153, 465-472.
http://dx.doi.org/10.1016/j.surg.2012.10.005

[39]   Robinson, P. and Muir, L. (2009) Wrong-Site Surgery in Orthopaedics. Journal of Bone and Joint Surgery, 91, 1274-1280.
http://dx.doi.org/10.1302/0301-620X.91B10.22644

[40]   Eisenberg, J.M. (2000) Continuing Education Meets the Learning Organization: The Challenge of a Systems Approach to Patient Safety. The Journal of Continuing Education in the Health Professions, 20, 197-207.
http://dx.doi.org/10.1002/chp.1340200403

[41]   Institute of Medicine (2000) Committee on Quality of Healthcare in America. In: Kohn, L.T., Corrigan, J.M. and Donaldson, M.S., Eds., To Err Is Human: Building a Safer Health System, The National Academy Press, Washington DC.

[42]   Leape, L.L. (2004) Errors are Not Diseases: They Are Symptoms of Diseases. The Laryngoscope, 114, 1320-1321.
http://dx.doi.org/10.1097/00005537-200408000-00002

[43]   Michaels, R.K., Makary, M.A., Dahab, Y., et al. (2007) Achieving the National Quality Forum’s “Never Events”: Prevention of Wrong Site, Wrong Procedure, and Wrong Patient Operations. Annals of Surgery, 245, 526-532.
http://dx.doi.org/10.1097/01.sla.0000251573.52463.d2

[44]   The Joint Commission. Sentinel Event Data: Event Type by Year (1995-2011) (accessed 14 July 2012).
http://www.jointcommission.org/sentinel_event.aspx.

[45]   Agency for Healthcare Research and Quality. Patient Safety Primers: Never Events. Patient Safety Network (accessed 2 March 2012).
http://psnet.ahrq.gov/primer.aspx?primerID53

[46]   Kwann, M., Studdert, D.M., Zinner, M.J., et al. (2006) Incidence, Patterns, and Prevention of Wrong-Site Surgery. Archives of Surgery, 141, 353-358.
http://dx.doi.org/10.1001/archsurg.141.4.353

[47]   National Patient Safety Agency. National Reporting and Learning Service (accessed 30 May 2015).
www.nrls.npsa.nhs.uk/

[48]   García-Germán Vázquez, D., et al. (2009) Wrong Site Surgery. Revista Espanola de Cirugía Ortopédica y Traumatología, 53, 332-339.
http://dx.doi.org/10.1016/j.recot.2009.01.004

[49]   Canale, T.S. (accessed 30 May 2015) OK Plan to End Wrong-Site Surgeries. October 1997 Bulletin, American Academy of Orthopaedic Surgeons.
http://www2.aaos.org/bulletin/oct97/wrong.htm

[50]   Levy, D.A. (1998) No Defense for Wrong-Site Surgery. AAOS Bulletin, 46, 18.
http://www2.aaos.org/bulletin/jun98/legalcol.htm

[51]   Wong, D.A. (accessed 30 May 2015) Surgical Site Marking Comes of Age. April 2004 Bulletin, America Academy of Orthopaedic Surgeons.
http://www2.aaos.org/bulletin/apr04/feature1.htm

[52]   Ausman, J.I. (1999) The Business of Surgery: Business Principles Applied to Preoperative Planning, Operating Room Management, and Surgical Strategy. Surgical Neurology, 51,113-114.

[53]   Devine, J., Chutkan, N., Norvell, D.C. and Dettori, J.R. (2010) Avoiding Wrong Site Surgery. Spine, 35, S28-S36.
http://dx.doi.org/10.1097/BRS.0b013e3181d833ac

[54]   Joint Commission. A follow-Up Review of Wrong Site Surgery (accessed 16 February 2014).
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm

[55]   Perlis, C.S., Campbell, R.M., Perlis, R.H., Malik, M. and Dufresne, R.G.J. (2006) Incidence of and Risk Factors for Medical Malpractice Lawsuits among Mohs Surgeons. Dermatologic Surgery, 32, 79-83.
http://dx.doi.org/10.1097/00042728-200601000-00016

[56]   Neily, J., Mills, P.D., Eldridge, N., Dunn, E.J., Samples, C., Turner, J.R., et al. (2009) Incorrect Surgical Procedures within and outside of the Operating Room. Archives of Surgery, 144, 1028-1034.
http://dx.doi.org/10.1001/archsurg.2009.126

[57]   Al-Rawi, H. and Varma, S. (2012) The Use of a Hand-Held Mirror to Reduce Litigation and Improve Communication in Dermatological Surgery. British Journal of Dermatology, 167, 446-447.
http://dx.doi.org/10.1111/j.1365-2133.2012.10866.x

[58]   Hussain, W. (2012) Avoiding Wrong Site Surgery: How Language and Technology Can Help. British Journal of Dermatology, 167, 1186.
http://dx.doi.org/10.1111/j.1365-2133.2012.11024.x

[59]   Ibrahim, S.F. (2014) Wrong-Site Surgery in Dermatology. JAMA Dermatology, 150, 558-559.

[60]   Perri, A.J., Chan, C., Uchida, T. and Wagner, R.F. (2008) Patients’ Recall of Visible Skin Biopsy Sites. Skin Cancer, 23, 61-67.

[61]   DiGiovanni, C.W., Kang, L. and Manuel, J. (2003) Patient Compliance in Avoiding Wrong-Site Surgery. Journal of Bone and Joint Surgery, 85, 815-819.

[62]   Campbell, R.M., Perlis, C.S., Malik, M.K. and Dufresne, R.G. (2007) Characteristics of Mohs Practices in the United States: A Recall Survey of ACMS Surgeons. Dermatologic Surgery, 33, 1413-1418.
http://dx.doi.org/10.1097/00042728-200712000-00001

[63]   Holmkvist, K.A., Rogers, G.S. and Dahl, P.R. (1999) Incidence of Residual Basal Cell Carcinoma in Patients Who Appear Tumor Free after Biopsy. Journal of the American Academy of Dermatology, 41, 600-605.

[64]   Rossy, K.M. and Lawrence, N. (2012) Difficulty with Surgical Site Identification: What Role Does It Play in Dermatology? Journal of the American Academy of Dermatology, 67, 257-261.
http://dx.doi.org/10.1016/j.jaad.2012.02.034

[65]   McGinness, J.L. and Goldstein, G. (2010) The Value of Preoperative Biopsy-Site Photography for Identifying Cutaneous Lesions. Dermatologic Surgery, 36, 194-197.
http://dx.doi.org/10.1111/j.1524-4725.2009.01426.x

[66]   Ke, M., Moul, D., Camouse, M., Avram, M., et al. (2010) Where Is It? The Utility of Biopsy-Site Photography. Journal of the American Academy of Dermatology, 36, 198-202.
http://dx.doi.org/10.1111/j.1524-4725.2009.01425.x

[67]   Jawed, S.I., et al. (2014) Dermoscopy to Identify Biopsy Sites Before Mohs Surgery. Dermatologic Surgery, 40, 334-337.

[68]   Laumann, A.E. and Derick, A.J. (2006) Tattoos and Body Piercings in the United States: A National Data Set. Journal of the American Academy of Dermatology, 55, 413-421.
http://dx.doi.org/10.1016/j.jaad.2006.03.026

[69]   Chuang, G.S. and Gilchrest, B.A. (2012) Ultraviolet-Fluorescent Tattoo Location of Cutaneous Biopsy Site. Dermatologic Surgery, 38, 479-483.
http://dx.doi.org/10.1111/j.1524-4725.2011.02238.x

[70]   Chameleon Body Art Supply. Material Safety Data Sheet for BMX1000-Chameleon Tattoo Ink.

[71]   Chuang, G.S. and Gilchrest, B.A. (2012) Ultraviolet-Fluorescent Tattoo Location of Cutaneous Biopsy Site. Dermatologic Surgery, 38, 479-483.
http://dx.doi.org/10.1111/j.1524-4725.2011.02238.x

[72]   Lemperle, G., Romano, J.J. and Busso, M. (2003) Soft Tissue Augmentation with Artecoll: 10-Year History, Indications, Techniques, and Complications. Dermatologic Surgery, 29, 573-587.
http://dx.doi.org/10.1046/j.1524-4725.2003.29140.x

[73]   Shah, R.K., Kentala, E., Healy, G.B. and Roberson, D.W. (2004) Classification and Consequences of Errors in Otolaryngology. The Laryngoscope, 114, 1322-1335.
http://dx.doi.org/10.1097/00005537-200408000-00003

[74]   Shah, R.K., Nussenbaum, B., Kienstra, M., et al. (2010) Wrong-Site Sinus Surgery Inotolaryngology. Otolaryngology-Head and Neck Surgery, 143, 37-41.
http://dx.doi.org/10.1016/j.otohns.2010.04.003

[75]   Stahel, P.F., Sabel, A.L., Victoroff, M.S., et al. (2010) Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Data-Base of Physician Self-Reported Occurrences. Archives of Surgery, 145, 978-984.
http://dx.doi.org/10.1001/archsurg.2010.185

[76]   Knight, N. and Aucar, J. (2010) Use of an Anatomic Marking Form as an Alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. The American Journal of Surgery, 200, 803-807; Discussion 807-809.
http://dx.doi.org/10.1016/j.amjsurg.2010.06.010

[77]   Haynes, A.B., Weiser, T.G., Berry, W.R., et al. (2009) A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. The New England Journal of Medicine, 360, 491-499.
http://dx.doi.org/10.1056/NEJMsa0810119

[78]   De Vries, E.N., Prins, H.A., Crolla, R.M., et al. (2010) Effect of a Comprehensive Surgical Safety System on Patient Outcomes. The New England Journal of Medicine, 363, 1928-1937.
http://dx.doi.org/10.1056/NEJMsa0911535

[79]   Panesar, S.S., Noble, D.J., Mirza, S.B., et al. (2011) Can the Surgical Checklist Reduce the Risk of Wrong Site Surgery in Orthopaedics?—Can the Checklist Help? Supporting Evidence from Analysis of a National Patient Incident Reporting System. Journal of Orthopaedic Surgery and Research, 6, 18.
http://dx.doi.org/10.1186/1749-799x-6-18

[80]   Gawande, A. (2009) The Checklist Manifesto. 1st Edition, Metropolitan Books, New York, 79.

[81]   Clarke, J.R., Johnston, J., Blanco, M. and Martindell, D.P. (2008) Wrong-Site Surgery: Can We Prevent It? Advances in Surgery, 42, 13-31.
http://dx.doi.org/10.1016/j.yasu.2008.03.004

[82]   DiGiovanni, C.W., Kang, L. and Manuel, J. (2003) Patient Compliance in Avoiding Wrong-Site Surgery. Journal of Bone and Joint Surgery, 85, 815-819.

[83]   Bergal, L.M., Schwarzkopf, R., Walsh, M. and Tejwani, N.C. (2010) Patient Participation in Surgical Site Marking: Can This Be an Additional Tool to Help Avoid Wrong-Site Surgery? Journal of Patient Safety, 6, 221-225.
http://dx.doi.org/10.1097/PTS.0b013e3181fd19ec

[84]   Knight, N. and Aucar, J. (2010) Use of an Anatomic Marking Form as an Alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. The American Journal of Surgery, 200, 803-807; Discussion 807-809.
http://dx.doi.org/10.1016/j.amjsurg.2010.06.010

[85]   Mahar, P., Wasiak, J., Batty. L., Fowler. S., Cleland, H. and Gruen, R.L. (2012) Interventions for Reducing Wrong-Site Surgery and Invasive Procedures. Cochrane Database of Systematic Reviews, No. 9, Article No. CD009404.
http://dx.doi.org/10.1002/14651858.cd009404.pub2

[86]   Chang, H.-H., Lee, J.-J., Cheng, S.-J., et al. (2004) Effectiveness of an Educational Program in Reducing the Incidence of Wrong-Site Tooth Extraction. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 98, 288-294.
http://dx.doi.org/10.1016/j.tripleo.2004.01.018

[87]   Dagi, T.F., Berguer, R., Moore, S. and Reines, H.D. (2007) Preventable Errors in the Operating Room-Part 2: Retained Foreign Objects, Sharps Injuries, and Wrong Site Surgery. Current Problems in Surgery, 44, 352-381.
http://dx.doi.org/10.1067/j.cpsurg.2007.04.002

[88]   Giles, S.J., Rhodes, P., Clements, G., et al. (2006) Experience of Wrong Site Surgery and Surgical Marking Practices among Clinicians in the UK. BMJ Quality and Safety, 15, 363-368.
http://dx.doi.org/10.1136/qshc.2006.018333

[89]   Liou, T.-N. and Nussenbaum, B. (2014) Wrong Site Surgery in Otolaryngology—Head and Neck Surgery. The Laryngoscope, 124, 104-109.
http://dx.doi.org/10.1002/lary.24140

[90]   American Academy of Ophthalmology Eliminating Wrong Site Surgery (accessed 30 May 2015).


 
 
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