Surgical Site Marking Policy

SURGICAL SITE MARKING POLICY
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Version 3
Sub-committee approval group CHAT Governance Committee
Document Manager (job title) WHO Lead - Consultant Anaesthetist
Date ratified 01 March 2022
Date issued 06 April 2022
Review date 28 February 2025
Electronic location Clinical Policies and Theatre SOPs

LocSSIPs Policy for Performance of the World Health
Organisation (WHO) Surgical Safety Checklist in
Related Procedural Documents
Theatres
Consent to Clinical Examination and treatment policy
Surgical Site Marking, Surgical Mark, Procedure Site
Key Words (to aid with searching)
Marking
Summary
The purpose of this policy is to clarify and inform a universally acceptable method within Portsmouth
Hospitals NHS Trust (the Trust), by which patients undergoing a surgical procedure will have their
operative site marked appropriately and accurately. In addition, the surgical site marking is part of the
series of checks and to prevent wrong site surgery in accordance with the WHO checklist prior to incision.
Version tracking
Date
Version Brief Summary of Changes Author
Ratified
3 01.03.2022 • Urology marking procedures updated Consultant Anaesthetist
2 17.10.2017 • No changes Consultant
1 30.10.2014 • New policy Consultant

Version 3 Review date: 29/02/2025 (unless requirements change) Page 1 of 15
CONTENTS
PROCESS ...............................................................................................................................................................3
1. INTRODUCTION ........................................................................................................................................4
2. SCOPE .......................................................................................................................................................4
3. PROCESS ...................................................................................................................................................5
4. TRAINING REQUIREMENTS .......................................................................................................................9
5. REFERENCES AND ASSOCIATED DOCUMENTATION .................................................................................9
6. EQUALITY IMPACT SCREENING ...............................................................................................................10
7. MONITORING COMPLIANCE ...................................................................................................................10
Appendix A: Roles and Responsibilities ..............................................................................................................11
Appendix B: Definitions ......................................................................................................................................12
Appendix C: Part 2 Urology WHO .......................................................................................................................13
Appendix D: Urology TIME OUT .........................................................................................................................14
Appendix E: WHO Safer Surgery Checklist .........................................................................................................15

PROCESS
For quick reference the guide below is a summary of actions required. Additional details, by exception to cover
any additional notes that supplement the quick reference guide can be found in Section 3 – Process.
Marking the operative site

Is an essential part of the preoperative verification process to prevent wrong site surgery with the core
steps:
• The consent process in accordance with Royal college Surgeons Good Surgical Practice 2009
Guideline (Section 4.1)
• Surgical site marking (covered in this policy)
• Preoperative verification checklist (Theatre Checklist in the PHT surgical integrated record)
• WHO safer surgery checklist (specifically the Part Two Time Out)
1. Who makes the mark? The person responsible for making the mark is the surgeon performing the
procedure who is familiar with the patient, or a deputy also present as part of the team for the
procedure. The surgeon who makes the mark should also be present at the specific procedure.
2. Specialties can designate other members of staff to mark in collaboration with the surgeon under
their governance structure e.g., stoma nurses
3. When should marking occur? The mark should be made prior to the patient transfer to the
operating theatre. In order to ensure that the surgical mark supports the check in process/WHO
Safer Surgery Checklist and can be corroborated against the consent and the patient ID band.
4. How should marking occur? The mark should be made before the patient arrives in the theatre
complex using a marker that is sufficiently permanent to remain visible after completion of the skin
preparation.
5. Make the mark at or near the incision site preferably with in 6 inches of the incision. Do NOT mark
any non-operative site(s) unless it is clinically obvious that this is not the operative site(s).
6. The mark should be an arrow where possible.
7. The mark should be positioned to be visible after the patient is prepped and draped.
8. The site for all procedures that involve incisions, percutaneous punctures or insertion of instruments
must be marked (unless covered by the exemptions in section 3.4.)
9. At a minimum, mark all cases involving laterality, multiple structures (fingers, toes, lesions), or
multiple levels.
10. Verification of the site mark should take place during the "sign in" of the WHO safer surgery
checklist using the consent form, and confirmed with the conscious patient before the start of
sedation.
11. A defined process should be in place for patients who refuse site marking.

1. INTRODUCTION
The best available evidence (international) puts the incidence of wrong-site surgery at 1-2 per 100,000
procedures (disturbingly high number for a never event).
“The training, competence and good intention of the surgeon, doctor, Dentist or health care professional
alone are not sufficient to prevent wrong site procedures.”
Prevention therefore requires an active process by the entire surgical team, not just by the operating
surgeon, utilising a standardised peri-operative process designed to prevent such never events. At
Portsmouth Hospitals NHS Trust the core steps are:
• The consent process in accordance with Royal college Surgeons Good Surgical Practice 2009
Guideline Section 4.1
• Surgical site marking (covered in this policy)
• Preoperative verification checklist (Theatre Checklist in the PHT surgical integrated record)
• WHO Safer Surgery Checklist Part Two Timeout – Before Procedure Started
This policy has been formulated in response to the recommendations made by the National Patient Safety
Agency (NPSA) and is designed to complement the World Health Organisation (WHO) checklist
implemented on 1 June 2009.
1.1 Purpose
The purpose of this policy is to clarify and inform a universally acceptable method within Portsmouth
Hospitals NHS Trust (the Trust), by which patients undergoing a surgical procedure will have their
operative site marked appropriately and accurately. In addition, the surgical site marking is part of the
series of checks and to prevent wrong site surgery in accordance with the WHO checklist prior to
incision.
It will:
• Support the verification process for checking the surgical site
• Guide when the marking should be undertaken.
• Define Who should mark the surgical site
• Minimize the risk of surgery on the wrong site or wrong patient
• Minimize the risk of the wrong procedure being performed
• Inform and guide the operating surgeon as to the method used to mark the skin and operative
site
• Where anatomically the site will be marked
2. SCOPE
All Trust staff (including permanent, locum, secondee, students, agency, bank and voluntary), the
Ministry of Defence Hospital Unit, Joint Hospitals Group South (Portsmouth) and Retention of
Employment (ROE) staff must follow the policies agreed by the Trust. Breaches of adherence to Trust
policy may have potential contractual consequences for the employee.
In the event of an infection outbreak, pandemic or major incident, the Trust recognises that it may not
be possible to adhere to all aspects of this document. In such circumstances, staff should take advice
from their manager and all possible action must be taken to maintain ongoing patient and staff safety.
The Trust is committed to promoting a culture founded on the values and behaviours which will bring us
closer to achieving our vision of working together to drive excellence in care for our patients and
communities. All staff are expected to uphold the Trust Values of Working Together: For Patients, With

Compassion, As One Team, Always Improving and all leaders are expected to display and role model the
behaviours outlined in the Trusts Leadership Behaviours Model
This policy should be read and implemented with the Trust Values and Leadership Behaviours in mind at
all times
3. PROCESS
Marking the operative site
Vital part of the preoperative verification process to prevent wrong site surgery with the core steps prior
to starting a procedure:
1) The consent process in accordance with Royal college Surgeons Good Surgical Practice 2009
(Guideline Section 4.1)
2) Surgical site marking (covered in this policy)
3) Preoperative verification checklist (Theatre Checklist in the PHT surgical integrated record)
4) WHO safer surgery checklist (specifically Part One-Before Induction & Part Two-Before the
procedure started) before a surgical intervention e.g., skin incision or insertion of instrument through
a natural body orifice.
3.1 WHO MAKES THE MARK?

The principle should be that the surgeon/operator who makes the mark is then present during the
procedure.
3.1.1 The person who is ultimately responsibility for making the mark is the surgeon performing
the procedure, who should be familiar with the patient.
3.1.2 Marking may be delegated to a deputy who will be present as part of the team for the
procedure. However, the responsibility remains with the lead surgeon. If marking is delegated
to another doctor, they must be permitted through a training program to participate
in/perform the procedure.
3.1.3 Specialties can designate other members of staff to mark in collaboration with the surgeon.
This must be defined under their governance structure and include appropriate training and
processes to support good practice e.g., stoma nurses
3.2 WHEN TO MAKE THE MARK

The mark should be made prior to the patient transfer to the operating theatre. This ensures that
the supporting steps in the check in process confirming correct procedure and site, specifically the
WHO Safer Surgery Checklist, can then occur in the theatre (or equivalent) areas.
3.3 HOW TO MAKE THE MARK

3.3.1 The surgeon should verify the operation to be undertaken, matched against the patient ID
band leading to making of the mark.
This should be a process of checking the records, including diagnostic imaging results (e.g. X-
rays, scans and other electronic imaging) and other diagnostic test results (e.g. biopsies) with
the consent form. The patient should be involved, (prior to any sedative pre-medication)
including confirmation against their ID band, to verify the site/sites to be marked.

3.3.2 The mark should be made using a marker that is sufficiently permanent to remain visible after
completion of the skin preparation.
3.3.3 Make the mark at or near the incision site preferably with in 6 inches of the incision. Do NOT
mark any non-operative site(s) unless it is clinically obvious that this is not the operative
site(s). e.g., incision of instrument through natural body orifice during endourology
procedures where the mark may be made on another part of the patient body (see section
3.1.5.6)
3.3.4 The mark should be an arrow and where possible include an indication of the procedure. (e.g.,
use a description of procedure)
3.3.5 The mark should be positioned to be visible after the patient is prepped and draped. This may
not always be possible and the theatre team and surgeon responsible need to be aware of this
and be extra vigilante at the “time out” part of the WHO checklist.
3.3.6 The site for all procedures that involve incisions, percutaneous punctures, or insertion of
instruments must be marked, apart from exemptions Section 3.4 (e.g., single organ cases).
Including:
• The surface, level, specific digit or lesion to be operated on.
• Laterality. For procedures involving laterality of organs that have an incision or approach
from the midline or natural orifice the site should be marked and laterality marked.
• Stomas
3.3.7 At a minimum; mark all cases involving laterality, multiple structures (fingers, toes, lesions),
or multiple levels.
3.3.8 Verification of the site mark should take place during the " Part One-Before Induction" of the
WHO checklist with the consent form and a conscious patient, before the start of sedation.
3.4 Exceptions to Site Marking

3.4.1 Exemptions:
• Single organ cases (e.g., Cesarean section, cardiac surgery, gastrectomy, cystectomy).
• Interventional cases for which the catheter/instrument insertion site is not
predetermined (e.g., cardiac catheterization).
• Teeth BUT, indicate operative tooth name(s) on documentation OR mark the operative
tooth (teeth) on the dental radiographs or dental diagram.
• Premature infants, for whom the mark may cause a permanent tattoo.
• Cases where the side or site of surgery needs to be confirmed by examination or
exploration under anaesthetic (EUA).
• Cases where anatomically difficult or technically difficult to mark (e.g. perineum, acute
burns)
3.4.2 For any sites not marked, the proposed operation/procedure must be reviewed to verify
patient and procedure at the ‘Time Out’ part two of the WHO safer surgery checklist. This
must be undertaken in conjunction with a review of all relevant documentation, including:
the patient’s notes; appropriate charts; diagnostic imaging (correctly oriented); and a
‘double person’ check of all information. The procedure must not commence without this
review having occurred.

3.4.3 Patients refusing to have a mark must have this clearly documented in their notes and the
process for any sites not marked section 6.4.2 followed.
3.5 SPECIALTY SPECIFIC INSTRUCTIONS (not otherwise covered above)

3.5.1 Urology
3.5.1.1 Urology mark cases following this Surgical Site Marking Policy and use:
1) Elective theatre: the Urology Specific Part 2 of the Safer Surgery Checklist for
final verification of the correct procedure and side (Urology Timeout is part of
the checklist) The Urology Specific Part 2 of the Safer Surgery Checklist is visible
as a white board on the wall in each urology theatre.
(Appendix C)
2) Emergency/CEPOD theatre: use standard WHO Safer Surgery Checklist and use
the Urology Time Out before incision/start of the procedure for verification of
the correct procedure and side.
(Appendix D & E)
3.5.1.2 Use the Urology Specific Time Out referencing the Consent form, the mark and the
relevant imaging displayed for cases that involve surgery where laterality applies.
3.5.1.3 Use the relevant radiological images for procedures where radiology helps to
identify laterality prior to Incision, port insertion or incision to a natural orifice
during ureteroscopy (to be confirmed at team brief) e.g., nephrectomy,
ureteroscopy.
3.5.1.4 Urology Specific Time Out use: the time out must happen immediately before the
incision, port incision or incision of instrument via natural orifice.
If ureteroscopy occurs after another procedure the Urology Specific Timeout should
be repeated before entry to the ureter or incision of instrument via a natural orifice.
Urology Theatre (with modified Urology Safer Surgery Checklist on the wall in
theatre)
use the Urology Safer Surgery Checklist with the Urology Timeout incorporated
mounted on the wall and sign the paper section PART 2 on the WHO Safer Surgery
Checklist. (attached document appendix C)
Emergency Theatre (e.g., CEPOD) with a Urology Case

Use normal checklist process and use the Urology Time Out Immediately after the
WHO Safer Surgery Checklist PART 2 (attached document appendix 2)
3.5.1.5 The urology specific timeout.

Urology Time Out:
Before incision, port insertion or incision of instrument via natural orifice:

Surgeon:
1)What is the patients name, DOB and NHS number?
2)Do the details match on the ID band and consent form?
3)Surgeon to confirm by reference to the consent form, the mark and relevant the
Imaging displayed (section 3.5.1.3)
What is?

• The procedure
• The side
• The correct patient positioning
3.5.1.6 If the mark and the radiological check of the imaging displayed do not match, the
procedure should stop.
The options at this point include either:
1) validation of the correct site with a second consultant surgeon in consultation
and agreement with the theatre team
2) abandoning surgery and waking the patient up so they can be reconsented and
marked for surgery on another day
3.5.1.7 Marking in cases (e.g., Ureteroscopy) where the mark may be obscured by drapes,
image intensifier and/or patient position:
1) Make the main mark on the abdomen/flank.
2) Make an additional mark over the clavicle and supraclavicular fossa on the same
side
At the Urology timeout reference the mark by adjusting the drapes or if it is not
possible reference the supraclavicular/clavicular mark.
3.5.2 Ophthalmic Surgery

For single eye surgery a small mark should be made either on the forehead above the correct
eye, or on the lateral aspect of the eye between the lateral canthus and the ear, pointing to
the correct eye for treatment.
The exception is for planned bilateral procedures on both eyes (such as bilateral squint
surgery), but the laterality of such procedures should be well documented. The marking of a
child’s head/face must be assessed at the time of pre-assessment by the surgeon as to its
psychological appropriateness. If no mark is made, then the procedures referred to at 3.4.2
must be adhered to.
3.5.3 Bilateral Treatment

Whilst this policy focuses on laterality, specific anatomical sites, levels and areas, surgeons
must consider that it is possible to perform the wrong bilateral procedure(s). Therefore, site
marking for bilateral, identical, procedures are not required. If no mark is made, then the
procedures referred to at 3.4.2 must be adhered to.
3.5.4 Dental & Maxillofacial Surgery Involving Teeth

Teeth cannot be marked, instead an Orthopantomogram (OPG) should be printed as a paper
copy. The teeth to be operated on should be marked on the OPG in accordance with this
policy where the mark is made on the OPG.
The OPG with mark should be visible during the procedure and referenced in accordance
with the WHO Safer Surgery Checklist as the mark.
3.5.5 ENT Surgery

There may be occasions where marking the patient’s skin to ‘point’ to the correct site for
surgery may be inappropriate e.g. bilateral tonsillectomy/adenoidectomy, laryngectomy. In
these cases section 3.4.2 for any site not marked apply. For ENT surgical sites where a skin

incision is made on a specific side i.e. surgery on the external pinna and tympanotomy these
should be marked with an arrow accordingly.
3.5.6 Burr Holes

Incidents have been reported to the NPSA of wrong side burr-holes being carried out as a
result of and failure to mark the appropriate side for surgery before the patient arrives in
theatre. It is now acceptable practice to mark the side of the burr-hole to be carried out in
the usual manor as directed by the Royal College of Surgeons, Neuro-anaesthesia Society
and the Society of British Neurological Surgeons.
3.5.7 Digital Surgery

Each and every digit to be operated on must have an individual arrow pointing to and as
close as possible to the respective digit.
3.5.8 Anaesthetic Role and Local/Block Procedures

The Anaesthetist is formally responsible for the “Sign In” section of the WHO checklist and
it is one of their duties to ensure the marking and consent are correct.
The site of the local/block procedure should use the surgical mark and a formal verification
using the “Stop before you block” process prior to block insertion.
3.6 STERILITY OF MARKING

Research has been carried out to ascertain whether the use of a permanent ink marker to mark a
surgical site, affects the sterility of a patient’s skin after it has been cleaned with surgical preparation
solution.
The results showed that no growth was seen in the cultures of swabs taken on both the control group
(un-marked) and on the experimental group (marked). Pre-operative marking of surgical sites in
accordance with the Joint Commission protocol did not affect the sterility of the surgical field,
therefore providing support for the safety of surgical site marking (Cronen, et al . 2005).
4. TRAINING REQUIREMENTS
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. The training will be supervised/responsibility of the
clinical teams providing induction for new members of their surgical teams. This will be directed by the
specialty Clinical Director.
5. REFERENCES AND ASSOCIATED DOCUMENTATION

Internal
• WHO checklist policy, as adapted for use in Portsmouth Hospitals NHS Trust
http://www.porthosp.nhs.uk/about-us/policies-and-
guidelines/policies/Clinical/WHO%20Safer%20Surgery%20Checklist%20Policy.doc
• Consent to Clinical Examination and treatment policy http://www.porthosp.nhs.uk/about-

us/policies-and-
guidelines/policies/Clinical/Consent%20to%20Examination%20or%20Treatment%20Policy.docx
External
• World Health Organisation (WHO) – Implementation manual, Surgical Safety Checklist 1st Ed (2009)

• National patient safety Agency (NPSA) – Patient safety Alert 06 – Correct site surgery, making your
surgery safer (2005)
• How to guide to the five steps to safer surgery (NPSA)

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=92901
• Good Surgical Practice (2008) The Royal College of Surgeons of England
• Guide To Surgical Site Marking High 5s CEPPRAL

http://www.has-sante.fr/portail/upload/docs/application/pdf/2013-
05/guide_to_surgical_site_marking.pdf
• AfPP Correct Site Surgery http://www.afpp.org.uk
6. EQUALITY IMPACT SCREENING

The Trust is committed to ensuring that, as far as is 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 procedural document has been assessed accordingly. The assessment document is held centrally
and is available by contacting the Trust Policy Management Inbox.
7. MONITORING COMPLIANCE
This procedural document will be monitored to ensure it is effective and to provide assurance of
compliance.
The compliance with this policy will be responsibility of the Clinical Division, and the Specialty Clinical
Directors. Monitoring of compliance will be the responsibility of the division and specialty governance
groups and will involve:
Element to be Frequency of Reporting

Lead Tool Lead
monitored Report arrangements
Audit via the WHO See above Policy audit report See above
Safety Checklist Audit to:
of all patients who
CHAT Governance
have procedures in
Committee
Theatres.
Evidence of completed See above Policy audit report See above
training by staff to:
involved in surgical site
CHAT Governance
marking.
Committee
Evidence of collection See above Policy audit report See above
of adverse incident to:
reports and discussion
CHAT Governance
at mortality and
Committee
morbidity meetings
Documentary evidence See above Policy audit report See above
of inclusion in staff to:
induction.
CHAT Governance
Committee

Appendix A: Roles and Responsibilities
Director of Clinical Standards (Medical Director)

The Director of Clinical Standards has ultimate responsibility for ensuring that appropriate processes are in
place for the safe management of surgical patients, including preoperative marking.
Clinical Directors
Clinical Directors in each specialty have responsibility for ensuring their surgeons mark patients’ accordingly
and carry out the instructions within this policy.
Operating Surgeon (or deputy)

It is the responsibility of the operating surgeon or deputy to mark the operative site in accordance with this
policy
Anaesthetist
The Anaesthetist is formally responsible for the “Sign In” section of the WHO Safer Surgery Checklist it is one
of their duties to ensure the marking and consent are correct
Anaesthetists are responsible for checking the site of any proposed local/regional block using the surgical mark
and the “Stop before you block” process.
Who (who is responsible ?)

The operating surgeon is responsible for ensuring that each individual patient has been marked appropriately
prior to arrival in theatre.
The Operating Theatre Team

The operating theatre team carries out the WHO Safer Surgery Checklist has joint responsibility for ensuring
that the correct site has been identified prior to commencement of surgery.

Appendix B: Definitions
Integrated Surgical Pathway

Integrated care pathway/paperwork is the structured multidisciplinary care plan which details essential steps
and documentation for the care and preparation of patients for surgical/medical procedures in theatre areas.
World Health Organisation (WHO) Checklist: a checklist developed by the WHO and collaborators at the
Harvard School of Public Health, the checklist identifies key safety steps during perioperative care that should
be accomplished during every single operation no matter the setting or type of surgery. It has been shown to
significantly reduce complications and deaths from surgery.
Part Two of the WHO Safer Surgery Checklist (Timeout) : a momentary pause taken by the team just before
skin incision in order to confirm that several essential safety checks are undertaken and involves everyone in
the team.

Appendix C: Part 2 Urology WHO

On The Wall
PART TWO UROLOGY – BEFORE PROCEDURE

STARTED
Theatre Team responsibility
USING CONSENT FORM AND RELAVANT IMAGING :

Surgeon & Theatre Team to confirm:
Have speciality checks been discussed?

(imaging, prosthesis, confirm allergies)
Is the surgical count visible?
Are antibiotics required? Have they
been given?
Warming in place and switched on?
Glycaemic control considered?
Is VTE prophylaxis indicated? Is it in
place and switched on?
Urology Time Out:
Before incision, port insertion or incision of instrument via

natural orifice:
Surgeon:
2)Do the details match on the ID band and consent

form?
3)Surgeon to confirm by reference to the consent

form, the mark and relevant imaging displayed
What is?
The procedure
The side
The correct patient positioning
Complete with signature at the bottom of Part Two on the

paper WHO Safer Surgery Checklist

Appendix D: Urology TIME OUT
Urology Time Out:

Before incision, port insertion or incision of instrument via
natural orifice:
Surgeon:
2)Do the details match on the ID band and consent form?
3)Surgeon to confirm by reference to the consent form, the

mark and relevant Imaging displayed
What is?
The procedure
The side
The correct patient positioning

Appendix E: WHO Safer Surgery Checklist


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