Preoperative Signing of the Incision Site in Orthopaedic Surgery in Canada

Furey, Andrew MD; Stone, Craig MD, FRCS(C); Martin, Rod FRCS(C)

Journal of Bone & Joint Surgery - American Volume:
The Orthopaedic Forum
Author Information

Andrew Furey, MD; Faculty of Medicine, Memorial University of Newfoundland, 25 Wedgeport Road, St. John's, NF A1A 5A5, Canada. E-mail address:

Craig Stone, MD, FRCS(C); Division of Orthopaedic Surgery, Department of Surgery, Memorial University of Newfoundland, Health Sciences Centre, Room 1827, 300 Prince Phillip Drive, St. John's, NF A1B 3V6, Canada. E-mail address:

Rod Martin, FRCS(C); Division of Orthopaedic Surgery, Department of Surgery, Memorial University of Newfoundland, 342 Pennywell Road, St. John's, NF A1E 1V9, Canada. E-mail address:

Article Outline

Wrong-site surgery is an often catastrophic yet preventable problem. Reports of wrong-site surgery have been on the rise in the United States every year since 19951,2. The number of reported cases has increased from sixteen in 1998 to fifty-eight at the time of writing in 2001. Eleven cases occurred in the month of November 2001 alone1,2. These increases are cause for grave concern.

Wrong-site surgery is a concern for every surgical specialty. However, orthopaedic surgery has an inherently higher risk compared with other types of surgery. Orthopaedic surgeons frequently operate on extremities, and many diseases do not have ob-vious external abnormalities. Of the 126 reported cases of wrong-site surgery in the United States, 41% were orthopaedic-related procedures1,2.

Operating on the correct site can be ensured through a strict series of checks and rechecks involving the surgeons, nurses, residents, and patients. In 1994, the Canadian Orthopaedic Association (COA) began an educational program intended to prevent such mistakes from occurring. Their recommendations included marking the incision site with a permanent marker prior to entering the operating room3.

The rates of wrong-site surgery in orthopaedic procedures in Canada have been declining since 1987 ( Fig. 1 ). Since 1994, the number of cases has been reduced from thirteen cases per year to five cases per year in 20004. Most of the cases involved knee surgery, and, in all but one, the knee had not been marked4.

The purpose of this study was to evaluate the impact that the campaign to promote preoperative signing of the incision site had on Canadian orthopaedic surgeons by assessing the proportion of orthopaedic surgeons who currently sign the incision site.

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Materials and Methods

Of the 819 practicing orthopaedic surgeons in Canada, 200 from across the country were randomly selected from the COA membership list and assigned a number. In September 2001, the surgeons were sent a package explaining the purpose of the study and were asked to complete an anonymous one-page questionnaire and to return it in a preaddressed postage-paid envelope. The package also contained a response card with a separate preaddressed postage-paid envelope. The response cards were coded to ensure confidentiality, and they enabled the authors to determine who had responded while ensuring anonymity. If there was no response within three weeks of the original mailing, a second package was sent to the surgeon reminding him or her of the survey. The results were analyzed with use of descriptive statistics. Differences in categorical variables were analyzed with use of the chi-square test.

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Six surgeons had moved and seven others had retired, leaving 187 potential respondents. A total of 167 of them responded, for a response rate of 89%.

Of the 167 respondents, 101 (60%) stated that it was not a policy in their hospitals to mark the incision site preoperatively. Eighty-seven (52%) stated that they always marked the incision site and thirty-eight (23%) stated that they occasionally marked the incision site, while forty-one (25%) claimed that they never marked the incision site preoperatively ( Table I ). The most common reason stated for not signing the operative site was the surgeon's confidence in his or her knowledge of the patient's condition.

Of the 125 surgeons who always or occasionally marked the site, eighty-six (69%) used their initials and 117 (94%) stated that they marked the site immediately before entering the operating room. Sixty-six (53%) said that they used a skin marker, whereas fifty-nine (47%) said that they used a pen. Nineteen surgeons (15%) said that they learned to mark the site during residency training, whereas 107 (86%) said that they learned the approach in their practice.

One hundred and six respondents (63%) practiced in a teaching center, whereas sixty (36%) practiced in a nonteaching center ( Table II ). Forty (24%) had been practicing for less than ten years, sixty-one (37%) had been practicing for ten to twenty years, and sixty-six (40%) had been practicing for more than twenty years.

With use of a chi-square analysis, the data showed that surgeons in a teaching center were more likely to sign the site than were surgeons in a nonacademic center (p = 0.021). A second chi-square analysis demonstrated that surgeons who had been in practice longer were less likely to sign the sites (p = 0.023). Of the forty-two surgeons who did not mark the sites preoperatively, twenty-four (57%) had been in practice for more than twenty years ( Table III ).

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The problem of wrong-site surgery is entirely preventable. The incidence of wrong-site surgery has been increasing in the United States since 1995 and, in particular, over the past year1. In most cases, the surgeon was in error3. Perhaps more disturbing than the number of cases reported are the results of a survey of hand surgeons in the United States, which revealed that 27% of them admitted to having operated at the wrong site in the past1. In Canada, the overall trend in the number of reported cases of wrong-site surgery involving an orthopaedic procedure has apparently been declining since 19934. The decrease possibly could be due to the educational campaign introduced by the COA in 1994. Another potential factor may be the increased awareness of wrong-site surgery by both patients and allied health professionals. As a result of the increasing number of reported cases of wrong-site surgery in the United States, the American Academy of Orthopaedic Surgeons (AAOS) issued an advisory statement3 in 1997, referred to as Sign Your Site, which was similar to the program created by the COA. Currently, it is speculated that 60% of American orthopaedic surgeons mark the site of incision preoperatively1,2.

The potential for error in the operating room occurs at many levels. Errors can occur in patient charts, in mislabeling of radiographs, or in draping the wrong site. Patient education also may help to prevent wrong-site surgery. The Joint Commission on Accreditation of Healthcare Organizations advises patients and family members to make sure that there is total agreement between themselves, their primary care doctor and the surgeon about exactly what will be done and where.1 Ultimately, the responsibility lies with the surgeon. The surgeon should discuss the procedure with the patient, check the signed consent form, check the charts, check the radiographs, and initial the appropriate site preoperatively5. These checks in combination with nursing checks and discussion between nurses and physicians seem to be sufficient to eliminate the mistake of wrong-site surgery. To sign initials over the incision site preoperatively is a benign, quick, and easy method of ensuring right-site surgery. However, it is not uniformly practiced.

This study is descriptive in nature and has the limitations of being a survey. However, it had a very high response rate and yielded important information. The majority of surgeons surveyed practiced in a hospital where it was not policy to mark incision sites preoperatively. Although most surgeons surveyed signed the sites preoperatively, there was still a substantial proportion who did not.

As this study is descriptive, conclusions cannot be drawn with regard to cause and effect. However, it is interesting to note that after the campaign conducted by the COA to encourage preoperative marking of the incision site, the rate of reported wrong-site surgery declined.

In Canada, nearly all of the wrong-site surgeries involving the knee did not have the incision site marked preoperatively. However, in one of the cases reported by the Canadian Medical Protective Agency, the wrong knee was initialed, draped, and operated on4. This unfortunate incident emphasizes the need for accurate communication between staff and patients.

Although mistakes happen, wrong-site surgery is avoidable. A surprisingly small number of respondents said that it was policy in their hospitals to sign the incision site. Policies such as those suggested by the COA are feasible and easy to implement. Signing the incision site preoperatively is a quick, easy method that helps to prevent wrong-site surgery. The COA and the AAOS have taken steps in the right direction to ensure that the rate of such mistakes declines in the future. This study confirms that more than one-half (52%) of the surgeons in Canada always follow the COA guidelines for preoperative incision-marking. The campaign to educate surgeons, allied health staff, and patients should be continued, as it could lead to additional decreases in the incidence of wrong-site surgery.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

1. Joint Commission on Accreditation of Healthcare Organizations. A follow-up review of wrong site surgery. Sentinel Event Alert, issue 24; 2001 Dec 5.
2. Brown D. Surgical calamities on rise, group says. Reports of doctors operating on wrong body part-or patient-have increased. Washington Post. 2001 Dec 6; p A14.
3. American Academy of Orthopaedic Surgeons. Advisory Statement. Wrong-site surgery, February 2002. (Issued in September 1997.)
4. Canadian Medical Protective Association. Personal communication, Dec 2001.
5. Cowell H. Editorial. Wrong-site surgery. J Bone Joint Surg Am, 1998;80: 463.
Copyright 2002 by The Journal of Bone and Joint Surgery, Incorporated