The Newcastle upon Tyne Hospitals NHS Foundation Trust Pre-Operative Marking Version.: 6.1 Effective From: 01 April 2015 Expiry Date: 01 April 2018 Date Ratified: 17 December 2014 Ratified By: Theatre Users Group 1 Introduction Healthcare staff has a duty of care to prevent potential harm to the patient and with the implementation of clinical governance, also have a responsibility to ensure that adequate risk management systems are in place to prevent wrong site surgery. Pre-operative marking should be undertaken in conjunction with; NPSA Patient safety tice: Standardising wristbands improves patient safety. Patient Safety Alert: WHO Surgical Checklist. Correct Site Surgery Theatre Protocol (NUTH) Protocol for the Use of Check-List Alert Signs (NUTH) 2 Scope This policy is of primary interest to all surgeons, anaesthetists, perioperative practitioners working in an advanced role and ward staff. 3 Aims Preoperative marking has a significant role in promoting correct site surgery, including 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). Surgery performed at the incorrect anatomical site is rare; however it can be devastating for patients and it is recommended that a surgical plan is clearly documented in the patients notes indicating the surgical procedure and site if possible. 4 Duties (Roles and responsibilities) Responsibility for ensuring the application of this policy lies with the individual Clinical Directors, supported by the Directorate Managers and Matrons. The document is also relevant to all who undertake such procedures, including: Anaesthetists Nurses Operating Department Practitioners Page 1 of 10
Operating theatre managers Surgeons Cardiologists Dental practitioners General practitioners Health Care Assistants Any other employees involved in the care of patients undergoing invasive procedures. 5 Definitions NPSA WHO National Patient Safety Agency World Health Organisation 6 Pre-Operative Skin Marking It is the responsibility of the surgical practitioner performing the operative procedure to ensure that, where side or site could be confused, the site is marked with an indelible skin marker to indicate Right or Left side. For procedures where the patient is undergoing general anaesthesia or sedation, the person performing the procedure has a duty to see the patient or, if he/she is unavailable, to delegate this to a member of the operative team before induction of anaesthesia or sedation commences. This person should check the consent form and examine the patients records to ensure that they relate to the patient and the correct procedure and operative site is identified. The anaesthetist and anaesthetic assistant/practitioner should verify the correct site and consent as part of the WHO Safer Surgery Checklist sign-in prior to the induction of anaesthesia. The scrub practitioner should verify with the surgeon and operating theatre team, the correct side to be operated on by confirming the correct details in the patients records. If failure of any of the checks occurs, the surgeon in charge should assess the situation and either, return the patient to the ward or note and sign a decision to proceed at risk. If the patient is returned to the ward an incident form must be completed in line with governance procedure. The patient must be competent to consent to pre-operative skin marking on their own behalf, has fully understood the nature of the proposed procedure and has been informed of the relevant benefits and risks. Working with interpreters or family members of carers is essential for patients with limited or no English. Advocates may be needed to support people with a learning disability or dementia Page 2 of 10
Confidentiality is an especially sensitive issue for trans individuals. non-essential disclosure of their trans status or history should occur. If a person holds a Gender Recognition Certificate you could be breaking the law if you unreasonably disclose their former gender to others. If required an indication of risk should be identified as clinical or non-clinical risk only, details are not required on the printed list. If surgery is carried out at risk a full root cause analysis is recommended. 6.1 Circumstances Where Marking is Appropriate Preoperative marking must take place where there is any potential for confusion of site or side of surgery. This includes procedures requiring a midline or laparoscopic approach but the operative target is on one side only. The side of the operative target should be clearly documented on the surgical care plan, consent form and operating list e.g. Right L5/S1 Nerve Root Decompression. The patient should be marked with an arrow pointing to one side of the operative target using an indelible skin marker that should be allowed to dry for a minimum of 30 seconds. If there is a risk of transfer of the mark to another part of the body before drying, then the word Right / Left (or a capital R / L) should be used instead of an arrow. If the preoperative site is unavailable for marking because of bandages, POP, burns etc. the site should be marked as close as possible to the operative site. It is desirable that the mark should remain visible after the application of the drapes. 6.2 Circumstances Where Marking May t be Appropriate Emergency surgery should not be delayed due to lack of preoperative marking if there is a risk of harm to the patient as a consequence. Teeth and mucous membranes Bilateral simultaneous organ surgery such as bilateral tonsillectomy or squint surgery. Bilateral sites should be marked when there are occasions when only single sided surgery is to be performed. Situations where laterality of surgery needs to be confirmed following examination under anaesthetic or exploration in theatre. Where no alternatives of side exist as a result of anatomical positions such as appendectomy or cholecystectomy. Where the operative target is bilateral via a midline, standard or laparoscopic approach. In this instance the operation should be recorded as bilateral. It is recommended that the operating list should also detail midline incision to avoid any ambiguity. Angiography does not require preoperative marking. Skin laser procedures are excluded from the policy because of the risk of permanent tattooing associated with this procedure. Page 3 of 10
6.3 Operating List The operating list should include details of the side and site where appropriate. Surgery that does not require preoperative marking must be recorded as unsided on the operating list. All operation details should be recorded as Left, Right, Bilateral or Unsided. In some instances it is essential to provide information regarding the specific site of surgery e.g. lateral or medial aspect. To avoid ambiguity fingers should be described as thumb, index, middle, ring or little and toes as hallux (or big), second, third, fourth or fifth (or little). 6.4 Secondary Operating Sites Secondary operating sites are usually for the taking of grafts such as bone, fat, fascia, blood vessels or skin. Care should be taken to clearly identify secondary operation sites so that they cannot be confused with the primary site. The site and laterality of the secondary site should be clearly identified on the operating list when the location is known preoperatively. If the need for two operation sites is identified preoperatively these should be marked 1 for the primary site and 2 for the secondary site if there is any risk of confusion with the primary site. This is particularly important when donor and recipient sites are on the same anatomical part, e.g. leg. 6.5 Preoperative Marking Recommendations 1 How to Mark An indelible skin marker must be used and allowed to dry for minimum of 30 seconds. The mark should be an arrow that extends to, or near to the incision site and remains visible after the application of skin prep. It is desirable that the mark should also remain visible after the application of drapes. If there is a risk of transfer of the mark to another part of the body before it dries, then the mark should state right or left (or capital R / L) rather than an arrow. 2 Where to Mark Surgical operations involving side (laterality) must be marked at or near the Incision. For digits on the hand or foot the mark should extend to the correct specific digit. The intended surgical site should be ascertained from reliable documentation and images. 3 Who Marks Marking should be undertaken by the operating surgeon or a nominated deputy that will be present in the operating theatre at the time of the patient s procedure. Page 4 of 10
4 With Whom The process of pre-operative marking of the intended site should involve the patient and/or family members/significant others wherever possible. Male and female practitioners are available when a practitioner of the same sex is required to promote the dignity of patients 5 Time and Place The surgical site should be marked on the ward or day care area prior to transfer of the patient to the operating theatre. Marking should take place before pre-medication is given if prescribed. 6 Verify The surgical mark must subsequently be checked against reliable documentation to confirm that it is a) correctly located and b) still legible. This checking should take place at each transfer of the patients care and end with a final verification prior to commencement of surgery. All team members should be involved in checking the mark. The ward nurse should identify from the operating list whether pre-operative marking is required. The ward nurse should visually check a mark is present where appropriate, whilst completing the assessment checklist for the preoperative patient and sign section 21 to indicate that the patient is marked. If the surgical procedure does not require a mark (see circumstances where marking may not be appropriate) the ward nurse should clearly write not applicable and sign section 21. Should the ward nurse discover the patient has not been marked or the mark is not visible, they must inform the theatre reception staff when transferring the care of the patient to theatres. The practitioner responsible for checking the patient into theatre should ask whether or not they have been marked pre-operatively. It may be impossible to maintain a patients dignity by asking them to reveal the preoperative mark in a public area therefore a verbal confirmation is acceptable in these circumstances. Should the theatre practitioner discover that the patient has not been marked (with the exception of un -sided operations), they must inform the surgeon and a Checklist Alert sign should be attached to the front of the patients notes (see Protocol for the use of Checklist Alert Signs). The checklist alert sign must remain on the front of the notes until the patient has been marked. The practitioner undertaking this check is responsible for signing section 25 of the preoperative checklist. Page 5 of 10
Once informed the surgeon may choose to mark the patient in the anaesthetic room to ensure the patients dignity is maintained. The anaesthetic assistant must be informed during handover from reception staff that the patient has not been marked and they in turn must inform the anaesthetist. The patient must not be anaesthetised until marking has been undertaken. On arrival in the anaesthetic room the anaesthetic assistant and anaesthetist will check the identity of the patient and the operation to be performed. The operation site and mark must also be checked particularly where cases of laterality occur, as part of the WHO Surgical Safety Checklist sign-in. The patient must not be anaesthetised until marking has been undertaken. If the procedure is being done under local anaesthetic administered by the surgeon, this check must be undertaken by the surgeon and the theatre practitioner. 6.6 Final Check Knife Check Time Out procedure On arrival in the operating theatre the patient s identity should be confirmed by the scrub assistant and the circulating practitioner using the name bracelet checked against the operating list, consent form and if necessary the patient s notes as part of the WHO Time-Out procedure. Once the patient has been prepared and draped, and prior to the scrub assistant handing the surgeon the instrument to commence surgery, a final knife check must be performed. The knife check is led by the scrub assistant and will include the operating surgeon and the circulating practitioner. For local anaesthetic cases without a scrub practitioner, it will include the surgeon and the circulating practitioner. The knife check will include the following: The marking of the correct site checked against the consent form, operating list and if necessary the patients notes. Procedure to be performed checked against the operating list, consent form and if necessary the patients notes. The circulating practitioner will sign the WHO Checklist to confirm that this has been done. When a patient is re-positioned and re-draped during the procedure, a second knife check will be undertaken (as above), to confirm the side/site prior to the scrub assistant handing the surgeon the instrument to re-commence surgery. The circulating practitioner will sign the WHO checklist again to confirm that this has been done. The surgeon has responsibility for ensuring that the knife checks have taken place and the anaesthetist must be satisfied that it has been done before allowing surgery to commence. Page 6 of 10
6.7 System Failure If failure of any of the preoperative checks occurs the surgeon in charge will assess the situation and decide whether to return the patient to the ward / day care area or note and sign a decision to proceed at risk. If the patient is returned to the ward / day care area a datix report must be completed in line with local governance procedure. A datix report must be completed if there is any deviation from the policy. A senior member of staff must offer the patient an explanation and apology. 7 Training Training of all surgeons and junior doctors must be carried out at their induction covering the WHO Checklist and the guidelines for surgical site marking. This will be facilitated by the designated clinical teams providing any new employee induction for surgical teams. This will be directed by the specialty lead. 8 Equality and diversity The Trust is committed to ensuring that, as far as reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 9 Monitoring compliance Compliance with this policy will be monitored by the Clinical Director with support from the Directorate Manager and Matrons, who from analysis of incident reports and Audit of Documentation, will provide a report to Theatre User Groups and the Clinical Governance and Quality Committee. Standard / process / issue Compliance with all process of preoperative skin marking Review of Datix incident reports and review of audit information and documentation Monitoring and audit Method By Committee Frequency Monitoring Clinical Theatre Annual Director User Group Directorate Manager Matrons Review Clinical Director Directorate Manager Matrons Theatre user Group Annual Page 7 of 10
10 Consultation and Review A review of incident reporting and audit documentation will be completed on an annual basis. A report will be provided for the Theatre User Groups and the Clinical Governance and Quality Committee. 11 References National Patient safety Agency N.P.S.A (2005) Patient Safety Alert Correct Site Surgery. Available at: Npsa.nhs.uk/EasysiteWeb/getresource.axd?AssetID=3477&type=Full &..Accessed June 2014. 12 Associated Documentation Safeguards for Invasive Procedures Page 8 of 10
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The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 30/12/2014 2. Name of policy: Pre-operative Marking 3. Name and designation of Author: Claire Winter & Sheina Baldwin 4. Names & Designations of those involved in the impact analysis screening process: Claire Winter, Sheina Baldwin & Lucy Hall 5. Is this a: Policy X Strategy Service Is this: New Revised X Who is affected: Employees X Service Users Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) Preoperative marking has a significant role in promoting correct site surgery, including 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). Surgery performed at the incorrect anatomical site is rare; however it can be devastating for patients and it is recommended that a surgical plan is clearly documented in the patients notes indicating the surgical procedure and site if possible 7. Does this policy, strategy, or service have any equality implications? Yes These have been taken into consideration in the final policy document. Pre Op Skin Marking2014 12 01 revised EAForm (Final).doc Page 1 of 5 Dec 2013
If, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: 8. Summary of evidence related to protected characteristics Protected Characteristic Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups related to this policy/service/strategy please refer to the Equality fact files available via the link below (add link) Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) Race / Ethnic origin (including gypsies and travellers) Interpreting service and policy E&D Training Communication errors are more likely when communicating with people with limited English. Errors and misinformation can occur when working with patients with limited or no English. Make it explicit that when working with patients with limited English family members and carers interpreters should be used. Advocates may be required for patients with learning disability or dementia. Sex (male/ female) Male and female practitioners are available when a practitioner of the same sex is required to promote the dignity of patients To ensure that patient dignity is maintained at all times a family member, significant other or appropriate available practitioner must be in attendance to support the cultural needs of the patient Pre Op Skin Marking2014 12 01 revised EAForm (Final).doc Page 2 of 5 Dec 2013
during the preoperative marking process. Religion and Belief Care of the deceased is incorporated into the policy Chaplaincy service provided with links to leaders of major faiths. Sexual orientation including lesbian, gay and bisexual people Evidence files used to raise awareness of the impact of discrimination on the mental health of LGB people through Age Dementia friendly wards You re Welcome Accreditation in children and young people s services Older people with dementia and children and young people may need additional Advocate support. Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section BSL Signers and Deaf Blind Guides are provided in the Trust LD Liason Nurse People with a disability particularly sensory and learning disability may need information in other formats and additional support. Carers and advocates may also need to be involved. Gender Reassignment Gender Identity sub group to identify and address needs in relation to Gender Identity People who have undergone gender reassignment surgery or are living in the gender opposite to their birth gender may be particularly sensitive about privacy and dignity in relation to exposure of their body. They may also have Pre Op Skin Marking2014 12 01 revised EAForm (Final).doc Page 3 of 5 Dec 2013
additional notes referring to them as their birth gender. Marriage and Civil Partnership N/A Maternity / Pregnancy Women s Health and Maternity Services provided by the Trust 9. Are there any gaps in the evidence outlined above. If yes how will these be rectified? 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement Yes X 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? PART 2 Signature of Author Pre Op Skin Marking2014 12 01 revised EAForm (Final).doc Page 4 of 5 Dec 2013
Claire Winter & Sheina Baldwin Print name CLAIRE WINTER Date of completion 30/03/2015 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.) Pre Op Skin Marking2014 12 01 revised EAForm (Final).doc Page 5 of 5 Dec 2013