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Duplication of surgical site marking
James S Davis1, Jagajan Karmacharya, Carl I Schulman
1DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. jdavis7@med.miami.edu
Journal of Patient Safety
|September 1, 2012
Summary
Wrong-site surgery is preventable with vigilance. A case of duplicated surgical site marking highlights the critical need for procedural team attentiveness to avoid errors.
Area of Science:
- Medical Safety
- Surgical Procedures
- Patient Care
Background:
- Wrong-site surgery is a serious patient safety event.
- The Joint Commission mandates surgical site marking to prevent such errors.
- Vigilance is crucial in avoiding surgical complications.
Observation:
- A case study involving a duplicated preprocedure surgical site mark is presented.
- The duplication occurred despite established protocols for site identification.
- This highlights a potential failure in the verification process.
Findings:
- A complete medical record review successfully identified and averted the potential wrong-site surgery.
- The incident underscores the risk associated with even minor deviations in marking procedures.
- Constant attentiveness from the entire procedural team is essential.
Implications:
- Reinforces the importance of meticulous adherence to surgical safety protocols.
- Emphasizes the need for robust verification systems beyond initial marking.
- Highlights the critical role of communication and vigilance among healthcare professionals to ensure patient safety.