Wednesday, 17 October 2012

Mark the site campaign


A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS
(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.


It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.


This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).


Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.


Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.


Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)
Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site


Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.


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PHL Taxi said...

Quite interesting and different post.. Keep posting..Stay blessed!!
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Shankarabarathi said...

Loving the information on this website , you have done great job on the posts. Thanks for providing such a great information with us.
Health Care in Chennai
Hospitals in Chennai

M HEMADRI said...

Hi Shankarabarathi

Thank you for your kind words. Can I request you to share the info with the CEOs of all the sponsored hospitals on your website. That way we can hopefully directly improve patient care, if they were to make this their official policy.

Hi PHL - very kind comments, thanks