Authors (including presenting author) :
Lo SKB(1), Law T(1), Leung CWA(1), Ng LKM(1), Yu CWR(1), Pang SY(2)
Affiliation :
(1)Department of Operating Theatre, Ruttonjee & Tang Shiu Kin Hospitals, (2)Department of Surgery, Ruttonjee & Tang Shiu Kin Hospitals
Keyword 1: :
Correct site surgery
Keyword 2: :
visible site marking during operation
Introduction :
Reports from the Hospital Authority Risk Alert have highlighted the frequent occurrence of wrong-site surgeries, underscoring the urgent need for systemic improvements to prevent critical patient harm and reputational damage. Despite existing protocols, gaps in awareness and adherence persist among surgical teams. This study aims to address these deficiencies by updating the verification system and to empower multi-disciplinary staff to monitor and feedback to maintain correct marking practices. The ultimate goal is to evaluate the effectiveness of an enhanced surgical site marking program to prevent the incidence of wrong-site surgeries.
Objectives :
The objective of the "智醒標記" program is to enhance patient safety by mandating the continuous visual availability of surgical site markings to prevent wrong-site surgery.
Methodology :
While standard HKEC guidelines exist, there is no specific requirement regarding the visual availability of site markings during operations. We have therefore revised our departmental guidelines to mandate that the marking must remain visible at the moment of 'knife on skin.' To support this, we launched the "智醒標記" program, incorporating lectures, visual aids, and slogans. Implementation is structured in two phases: initially focusing on elective cases, then extending to all procedures including emergency and minor operations. Clinical audits were conducted to assess pre- and post-education compliance. Data will be analyzed using statistical methods to evaluate improvements in marking accuracy.
Result & Outcome :
For the pre-audit result, there are 40 samples for the elective cases with 95% compliance rate (38/40). For the post-audit result, the compliance rate with “marking seen when a knife is on skin by a surgeon” is 100% in 40 samples. While reducing errors from 2 to 0 out of 40 cases may seem like a mere "5%" statistical change, it clinically prevent two serious outcomes from wrong site surgery. This is our responsibility to maintain highly professional and correct attitude to achieve a "Zero Harm" goal. The study’s findings ultimately enhance patient safety and organizational reputation across healthcare systems. Furthermore, it underscores the importance of continuous education and adherence to protocols in minimizing surgical errors in order to improve surgical safety practices. In summary, the "智醒標記" program has successfully elevated surgical safety standards, demonstrating that educational interventions and standardized visual requirements can effectively eliminate potential human error at the most critical stage of surgery. The clinical focus from "having a mark" to ensuring the mark is clearly visible to the surgeon at the moment of incision. This minimizes risks associated with marks being obscured by surgical drapes or erased during skin preparation. Reinforcing a culture of "zero tolerance" for wrong-site surgery by standardizing checking systems and fostering multidisciplinary adherence to correct marking practices. Limitation: The most difficult part of this project is compliance, for example, surgeons may do surgical site marking in ward for patient at the area where may not be seen after draping. In such cases, our frontline staff will notify the surgeon in OT to re-mark the site within seeable area (after draping) before the procedure starts. While requiring a surgeon to repeat the marking can be challenging, effective communication remains our indispensable strategy for minimizing errors in operating theatre.
