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Optimization and Prevention of Error in Surgical Site Identification
Shane P McTighe1, Lynsey Elaine Young2, Joshua E Lane2,3,4,5
1Martin Army Community Hospital, Department of Dermatology, Fort Benning, Georgia.
Background:
The occurrence of wrong-site surgery (WSS) marks a significant concern. In dermatologic and Mohs micrographic surgery, high procedural volume, healed biopsy sites, and multiprovider involvement amplify the risk.
Objective:
To systematically review and assess commonly used modalities in reducing the risk of WSS in the dermatologic and Mohs micrographic surgery setting.
Methods And Materials:
A comprehensive literature search was performed through PubMed and Google Scholar to identify studies published between 2014 and 2025 evaluating WSS prevention strategies in dermatologic surgery. Eligible studies focused on site verification, documentation, photography, technology adjuncts, and team-based protocols.
Results:
Effective WSS reduction strategies were multimodal, incorporating standardized documentation, prebiopsy and patient-captured photography, coordinate-based measurements, technological adjuncts such as ultraviolet imaging and smartphone apps, and structured team verification protocols. No single intervention was sufficient alone; layered safeguards and patient engagement were critical to minimizing risk.
Conclusion:
WSS remains a persistent but preventable challenge in dermatologic surgery. A systematic, multimodal approach integrating technical, procedural, and team-based safeguards meaningfully reduces risk and enhances surgical safety.
