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Correct Site Marking Policy

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					                   Correct Site
                   Marking: Policy




                       Southampton University
                          Hospitals NHS Trust




                                        May 2007



Issued: May 2007                   Page 1 of 11
Version: 1.0
                                      SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
Contents:
1.      Purpose of this Policy ................................................................................................................... 4
2.      Scope of this Policy....................................................................................................................... 4
3.      Links to other key Strategies & Policies ..................................................................................... 4
4.      Responsibilities of all staff ........................................................................................................... 4
5.      Principles........................................................................................................................................ 5
6.      Standards to be followed – see Policy Summary Sheet (Appendix 1)...................................... 5
7.      Failure to follow Policy.................................................................................................................. 6
8.      Circumstances where marking may not be appropriate ............................................................ 6
9.      Documentation & Verification of Marking ................................................................................... 6
10.     Communication and Education Plan for this document ............................................................ 7
11.     Review & Audit plan for this document ....................................................................................... 7
12.     References ..................................................................................................................................... 7
13.     Appendix 1 – Correct Site Marking Policy Summary Sheet....................................................... 9
14.     Appendix 2 – Theatre Pre-operative Checklist.......................................................................... 10
15.     Appendix 3 – Marking Verification Checklist ............................................................................ 11




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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST



                                   CORRECT SITE MARKING POLICY

                                                        SUMMARY
    •    Correct Site Marking and subsequent verification checks by staff play a
         significant role in promoting patient safety

    •    Marking should be clear using an indelible marker pen with particular attention
         being given to identifying laterality and/or specific digit/segment/level

    •    Marking should be undertaken by the operating clinician or nominated deputy
         who will be present in the operating theatre at the time of the patient’s procedure

    •    Active involvement and effective communication among all members of the
         clinical team is important for success

    •    Wherever possible, the patient (or legally designated representative) should be
         involved in the process

    •    A patient must not leave the pre-operative ward/area unless all information is
         present and correct, allowing the surgery/procedure to proceed

    •    Use of all of the supporting patient information must be used to verify the check
         e.g. patient’s notes, theatre list, consent form, radiological images (x-rays, scans,
         angiograms etc)
    •    Where the operation site is defined by imaging the images MUST be checked before
         marking the site

    •    If failure of any pre-operative check occurs the surgeon/operator in charge should
         be contacted, assess the situation and either:
                 Follow the Policy for marking the correct site using the supporting
                 information to verify the marking & document the decision to proceed in the
                 healthcare records OR
                 Return the patient to the ward/day care area

    •    All breaches of this policy must be reported via completion of an Incident Report
         Form

    •    A senior member of the medical & nursing staff must offer the patient an
         explanation and apology if the procedure is delayed/cancelled

    •    If surgery is carried out at the incorrect site, an Incident Report Form must be
          completed and the incident be subject to a full investigation


  Stationery stock number for ordering Correct Site Marking Verification Checklist: epro/Special Orders/
                                           number SHNS395



     This policy should be applicable or adaptable to all operative invasive procedures
          including procedures done in settings other than in the operating room

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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

                                     Title: Correct Site Marking Policy


1.       Purpose of this Policy
         To outline the Trust’s approach to the correct marking of patient’s operative/procedural sites and
         to provide appropriate guidance to Trust staff on the management of correct site surgery via the
         use of a verification checklist.

1.1      Summary
         Surgery/procedures performed at the incorrect anatomical site are rare. However, it can be
         devastating for patients and distressing for staff involved in such incidents. Correct site surgery
         (CSS) refers to operating on the correct side of the patient and/or the correct anatomical location
         or level (such as the correct finger on the correct hand).

         Across the NHS there is no single, standard method of marking a surgical site, which increases
         the likelihood of confusion and error. Despite high professional standards and excellent best
         practice at a local level, safety can be improved by using a consistent national standard for pre-
         operative marking and a verification checklist.

         The National Patient Safety Agency (NPSA) and the Royal College of Surgeons of England
         (RCS) have drawn up recommendations for surgical marking and a checklist to help staff rapidly
         confirm that steps to promote CSS have been taken. These are endorsed by a number of
         professional associations and Royal Colleges representing a cross-section of surgical staff.

1.2      Objectives/ success factors
         The objective of this Policy is to ensure that:

                  Patient safety is maintained through consistent practice of staff related to correct pre-
                  operative site marking & verification checks as outlined in this policy
                  Divisions can assure themselves that by using the verification checklist the standard for
                  ensuring correct site surgery is adhered to

2.       Scope of this Policy
         This Policy includes details related to:

                  The process of marking
                  Clarification as to who can mark operative sites
                  The process of checking, verification and documentation for correct site marking
                  Training requirements
                  Review & audit

3.       Links to other key Strategies & Policies
                  Risk & Safety Strategy
                  Patient Experience Strategy
                  Consent Policy
                  Correct Patient Identification Policy

4.       Responsibilities of all staff
                  This policy is applicable to all medical and clinical staff involved in the pre-operative and
                  peri-operative care of patients undergoing surgery or procedures where correct site
                  marking is required.
                  Non-compliance with this Trust Policy may result in disciplinary action.
                  All Divisions are responsible and accountable for ensuring that the standards of practice
                  outlined in this Policy are maintained and assured

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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
5.       Principles
                  Wrong site, wrong procedure, wrong person surgery can & must be prevented
                  A robust, comprehensive approach, using multiple complementarty strategies is required
                  to achieve the objectives of this policy
                  Active involvement & effective communication among all members of the clinical team is
                  important for success
                  To the extent possible, the patient (or legally designated representative) should be
                  involved in the process
                  Consistent implementation of a standardised approach as outlined in this policy
                  A requirement for site marking should focus on cases involving right/left distinction,
                  multiple structures (fingers, toes), the segment of a segmental organ wherever possible,
                  or levels (spine)
                  This policy should be applicable or adaptable to all operative invasive procedures that
                  expose patients to harm, including procedures done in settings other than the operating
                  room

6.       Standards to be followed – see Policy Summary Sheet (Appendix 1)

6.1      Pre-operative marking - The purpose is to mark unambiguuosly the intended site of
         incision/insertion

6.2      How to mark
         An indelible marker pen should be used. The mark should be an arrow that extends to a point just
         short of where the incision site is to commence and remains visible after the application of skin
         preparation. It is desirable that the mark should also remain visible after the application of theatre
         drapes.

6.3      Where/what to mark
         Surgical operations involving side (laterality) should be marked close to the intended incision. For
         digits on the hand and foot the mark should extend to the correct specific digit. Ascertain
         intended surgical site from reliable documentation and images.

         Specification of segment of segmented organ should be identified if appropriate i.e. lobe of lung
         or liver. It is acknowledged that in some circumstances the surgical intervention may be modified
         according to clinical findings in the course of the actual surgical procedure. This needs to be
         made clear to the patient as part of the consenting process and information discussion.

         If the operative procedure involves specific (skin) lesions, these must be marked.

6.4      Who Marks
        Marking should be undertaken by the operating clinician or nominated deputy who will be present
        in the operating theatre at the time of the patient’s procedure.

6.5      Involvement of others
         The process of pre-operative marking of the intended site should involve the patient wherever
         possible.

         In the case of children, parents should be involved in the process of marking.

         In the case of incapacitated/vulnerable adults, family members should be given the opportunity to
         be involved in the process of marking where appropriate.


6.6      Time & Place
         The surgical site should, ideally, be marked on the ward or day care area prior to the patient
         transfer to the operating theatre. Marking should take place before a sedative pre-medication.


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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
7.       Failure to follow Policy

7.1       If failure of any pre-operative check occurs, the surgeon in charge should be contacted, assess
          the situation and either:
         (a) Follow the Policy for marking the correct site using the supporting information to verify the
          marking and document the decision to proceed in the healthcare records or
         (b) Return the patient to the ward/day care area

7.2      All breaches of this policy must be reported via completion of an Incident Report Form.

7.3      A senior member of the medical and nursing staff must offer the patient an explanation and
         apology.

7.4      If surgery is carried out at the incorrect site, an incident form must be completed and the
         Divisional Management Team and the Risk & Patient Safety Dept notified immediately as per the
         management of a Serious Untoward Incident.

8.       Circumstances where marking may not be appropriate

8.1      Emergency surgery should not be delayed due to lack of pre-operative marking.

8.2      Teeth and mucous membranes.

8.3      Cases of bilateral simultaneous organ surgery such as bilateral tonsillectomy, squint surgery.

         Situations where the laterality of surgery needs to be confirmed following examination under
         anaesthesia or exploration in theatre such as revision of squint corrections.

9.       Documentation & Verification of Marking
         Pre-operative Check List (See Appendix 2)
9.1      SUHT staff must ensure that they use the yellow Theatre Man Pre-operative Checklist or an
         equivalent alternative, which may be adapted to meet local needs It is the responsibility of a
         qualified practitioner to complete the Pre-operative Checklist BEFORE the patient leaves the
         ward area.

         Correct Site Marking Verification Checklist (See Appendix 3)
9.2      Check 1 of the Correct Site Marking Verification Checklist requires the operating clinician or
         nominated deputy who will be present in the theatre at the time of the procedure to:
             Check the patient’s identity
             Check reliable documentation and/or images to ascertain intended surgical site
         Where the operation site is defined by imaging the images MUST be checked before
         marking the site
             Mark the intended site with an arrow using an indelible pen
          The operating clinician must sign the checklist to confirm the check has been completed.

9.3      Staff on the ward/day care area must complete Check 2 and sign the patient’s Corrrect Site
         Marking Verification Checklist to confirm that this check has been completed.
             Prior to leaving the ward/day care area the mark is inspected & confirmed against the
             patient’s supporting documentation
             Relevant imaging studies must accompany the patient or are available in the operating
             theatre/suite

9.4      It is the responsibility of the operating surgeon or a senior member of the team to ensure that
         Check 3 of the patient’s Correct Site Marking Verification Checklist is completed.
              In the anaesthetic room & prior to anaesthesia, the mark is inspected & checked against the
              patient’s supporting documentation
              Re-check the imaging studies that accompany the patient or ensure they are available in the
              operating theatre/suite
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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

9.5       The surgical, anaesthetic and theatre team involved in the intended operative procedure prior to
          commencement of surgery should pause for verbal briefing to confirm:
               Presence of the correct patient
               Marking of the correct site
               Procedure to be performed
           Use of all of the supporting patient information should be used to verify the check e.g.
          patient’s notes, theatre list, consent form, x-rays, scans. The patient’s Correct Site Marking
          Verification Checklist must be signed to confirm Check 4 has been completed.
          Active communication among all members of the surgical/procedure team must be consistently
          initiated and the procedure is not started until any questions or concerns are resolved.

9.6       New checklists will need to be fixed to the patient’s notes and completed for each new surgical
          procedure.

10.       Communication and Education Plan for this document

10.1      Communication and Dissemination Plan
          The launch of this Policy will be communicated & disseminated via:
             Governance arrangements within each Division & Care Group
             Corporate & Local Divisional/Care Group Induction programmes
             SUHTranet & Core Brief

10.2      Education and Support Plan
             Training on Correct Site Marking will be included in the Trust Consent training
             Correct Site Marking & Verification checking will be included in Induction programmes
             (Corporate/Local)
             The principles of the policy will be incorporated within a range of Risk & Safety education &
             training programmes at corporate/local level - including Root Cause Analysis Training &
             lessons learned

11.       Review & Audit plan for this document
              This Policy will be reviewed every 2 years
              Auditing of this Policy will be reviewed in line with the Trust’s annual prioritised Clinical Audit
              programme
              Other sources of assurance (both negative & positive) will be reviewed i.e. via Incident
              Reporting system. Staff should report ‘actual’ and ‘near-miss events’ which will be analysed
              as part of the quality assurance of this policy and clinical standards.

12.       References
      •   NPSA Patient Safety Alert 06 2 March 2005.

      •   The Joint Commission on Accreditation of Healthcare Organisations. Patient Safety Goals
          (2004). http://www.jcaho.org.

      •   Scheidt RC. Ensuring Site Surgery: Patient Safety First. The Association of Perioperative
          Registered Nurses. November 2002. Volume 76(5) pp 769-782.

      •   Veterans Health Administration (VHA). Ensuring Correct Surgery. VHA Directive 2002-070.
          November 2002. Department of Veterans Affairs, Washington, DC.

      •   The National Association of Theatre Nurses (NATN). Safeguards for Invasive Procedures; The
          Management of Risks (1998). NATN, Harrogate, Yorkshire. (Replacing Theatre Safeguards
          (1988). The Medical Defence Union (MDU), Medical Protection Society (MPS), Medical and
          Dental Union of Scotland (MDDUS), NATN and the Royal College of Nursing (RCN).


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                            SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
      •   Commission for Health Improvement. The Commission for Health Improvement Investigation into:
          Carmarthenshire NHS Trust. Report to the Assistant Minister for Health & Social Services for the
          National Assembly for Wales, November 2000.

      •   Committee on Orthopaedic Practice and Economics. The Canadian Orthopaedic Association.
          Position paper on wrong sided surgery in orthopaedics. June 1994.

      •   Joint Commission on Accreditation of Healthcare Organisation. A follow-up review of wrong site
          surgery, Sentinel Event Alert No. 6 (August 1998) at www.jcaho.org.

      •   Joint Commission on Accreditation of Healthcare Organisation. A follow-up review of wrong site
          surgery, Sentinel Event Alert No. 24 (December 2001) at www.jcaho.org.

      •   National Patient Safety Agency. CSS recommendation usability testing results from two NHS
          Trusts. January 2005 (unpublished).

13.       Appendix 1 – Correct Site Marking Policy Summary Sheet

14.       Appendix 2 – Theatre Pre-operative Checklist

15.       Appendix 3 – Correct Site Marking Verification Checklist




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                                 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST




13.      Appendix 1
        Correct Site Marking Policy Summary Sheet
The role of marking to promote correct
                                                                                       Pre-operative marking
site surgery
Pre-operative marking has a significant role in                       The National Patient Safety Agency (NPSA) and
promoting correct site surgery, including operating on                the Royal College of Surgeons of England (RCS)
the correct side of the patient and/or the correct                    strongly recommend pre-operative marking to
anatomical location or level (such as the correct                     indicate clearly the intended site for elective
finger on the correct hand).                                          surgical procedures.

Using the NPSA’s pre-operative marking                                1. How to mark
recommendations and verification checklist                            An indelible marker pen should be used. The mark
                                                                      should be an arrow that extends to, or near to, the
The NPSA requires organisations to have robust pre-                   incision site and remain visible after the application of
operative marking arrangements in place, which also                   skin preparation. It is desirable that the mark should
includes the use of a verification checklist.                         also remain visible after the application of theatre
                                                                      drapes.
SUHT staff must therefore ensure that they use
                                                                      2. Where to mark
either the yellow Theatre man pre-operative checklist
                                                                      Surgical operations involving side (laterality) should
or an equivalent alternative, which may be adapted to
                                                                      be marked at, or near, the intended incision. For
meet local needs. In addition, the Correct Site
                                                                      digits on the hand and foot the mark should extend to
Marking Verification Checklist must be used in all
                                                                      the correct specific digit. Ascertain intended surgical
cases (see overleaf)
                                                                      site from reliable documentation and images. Where
                                                                      the operation site is defined by imaging the images
New checklists will need to be fixed to patient notes                 MUST be checked before marking the site.
and completed for each new surgical procedure.
Therefore, all clinical Divisions will need to ensure                 3. Who marks
copies of the checklists are reproduced and made                      Marking should be undertaken by the operating
available at local level. The marking                                 clinician, or nominated deputy, who will be present in
recommendations will need to be accessible for                        the operating theatre at the time of the patient’s
reference.                                                            procedure.
                                                                      4. With whom
      Circumstances where marking may not be                          The process of pre-operative marking of the intended
                   appropriate                                        site should involve the patient wherever possible
                                                                      and/or parents or family members where the situation
1. Emergency surgery should not be delayed due to                     requires.
   lack of pre-operative marking.
                                                                      5. Time and place
2. Teeth and mucous membranes.                                        The surgical site should, ideally, be marked on the
                                                                      ward or day care area prior to patient transfer to the
3. Cases of bilateral simultaneous organ surgery                      operating theatre. Marking should take place before
   such as bilateral tonsillectomy, squint surgery.                   pre-medication.
                                                                      6. Verify
4. Situations where the laterality of surgery needs to
   be confirmed following examination under                           The surgical site mark should subsequently be
   anaesthesia or exploration in theatre such as                      checked against reliable documentation to confirm it
   revision of squint corrections.                                    is (a) correctly located, and (b) still legible. This
                                                                      checking should occur at each transfer of the
If, on the basis of clinical grounds, there is any                    patient’s care and end with a final verification e.g. in
variance from the Trust Policy on Correct Site                        theatre prior to commencement of surgery. All team
Marking, this must be documented in the                               members should be involved in checking & verifying
patient’s notes.                                                      the correct site/locality prior to commencement of the
                                                                      procedure.


PLEASE RETAIN CHECKLIST IN PATIENT’S
HEALTHCARE RECORDS




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14.       Appendix 2 – Theatre Pre-operative Checklist




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document
     15.   Appendix 3
                                                                                      Hospital Sticker/Patient Details
     Correct Site Marking Verification Checklist




DATE:

                                                                Responsibility             Signature to confirm check
                                                                                           completed
    Check 1 Preoperative Ward / Area                            The operating
    Check the patient’s identity                                surgeon, or                Signed:
    Check reliable documentation and radiological               nominated deputy
    images to ascertain intended surgical site                  who will be present
    Mark the intended site with an arrow using an               in the theatre at the      Print name:
    indelible pen                                               time of the patient’s
    Where the operation site is defined by imaging              procedure.
    the images MUST be checked before marking
    the site.

    Check 2 Preoperative Ward/Area
    Prior to leaving ward/day care area the mark is             Ward or day care           Signed:
    inspected and confirmed against the patient’s               staff.
    supporting documentation e.g Notes, Consent
    Form                                                                                   Print name


     Check 3 Anaesthetic Room
    In the anaesthetic room and prior to anaesthesia,           Operating surgeon          Signed:
    the mark is inspected and checked against the               or a senior member
    patient’s supporting documentation including                of the surgical team.
    Notes, Consent Form, Theatre List                                                      Print name
    Re-check imaging studies accompany patient or
    are available in operating theatre or suite
    The availability of the correct implant (if
    applicable)

    Check 4 Theatres                                                                        Name of Accountable Person
The surgical, anaesthetic and theatre team involved             Theatre staff directly
in the intended operative procedure prior to                    involved in the            Name of Lead Operator:
commencement of surgery should pause for verbal                 intended operative
briefing/‘time out’ to confirm by using the supporting          procedure.
documentation, xrays/scans/images etc:                                                     Signature:
     Presence of the correct patient                            Lead operator to
     Marking of the correct site                                sign as accountable
     Procedure to be performed                                  person                     Print name

•    A patient must not leave the preoperative ward/area unless all information is present and correct, allowing surgery to
     proceed.
•    If failure of any pre-operative check occurs, the surgeon in charge should be contacted, he/she should assess the
     situation and either:
                (a) Follow the Policy for marking the correct site using the supporting information to verify the marking and
                 document the decision to proceed in the healthcare records or
                (b) Return the patient to the ward/day care area
•    If the patient is delayed or returned to the ward/day care area due to inadequate preparation, an incident report form
     must be completed. A senior member of the nursing and medical staff should offer an explanation and apology to the
     patient.
•    If surgery is carried out at the incorrect site, an incident report form must be completed and the procedure for
     Reporting and Managing a Serious Incident instigated immediately.

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