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British Journal of Oral and Maxillofacial Surgery 51 (2013) 413–415

Available online at www.sciencedirect.com

arking the skin for oral surgical procedures: improvinghe WHO checklistreg J. Knepil ∗, Caroline T. Harvey, Andrea N. Beech

loucestershire Royal Hospital Department of Oral and Maxillofacial Surgery, Gloucestershire Royal Hospital, Great Western Rd, Gloucester GL1 3NN,nited Kingdom

ccepted 6 September 2012vailable online 1 October 2012

bstract

e present a system for marking the skin during oral surgical operations. This system identifies teeth to be extracted or exposed under generalnaesthesia. Removal of the wrong tooth can cause appreciable morbidity and leaves the surgeon and organisation liable for litigation andcrutiny by regulatory bodies. A recent review of claims to the NHS litigation authority between 1995 and 2010 showed that in the field ofral and maxillofacial surgery, dentoalveolar surgery resulted in the largest number of claims for negligence, of which removal of the wrongooth was one of the most common. In 2010/2011 the National Reporting and Learning System (NRLS) of the National Patient Safety AgencyNPSA) were notified of 20 incidents when the wrong tooth had been extracted, which accounted for 5% of all incidents reported. We haveherefore developed a robust marking system for oral surgical procedures in our hospital, which improves on the World Health Organisation

WHO) checklist. We have audited patients’ perceptions and the clinical application of our marking system, and have shown that the systems welcomed by patients, and is simple and effective for clinicians to use.

2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

eywords: Oral surgery; Surgical site marking; Wrong site surgery; WHO checklist; Never Event; Sentinel Event; Patient safety

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ntroduction

n the UK marking of the site of extra-oral disease is advo-ated for procedures in which there are multiple organsnvolved or laterality of organs. Despite the confirmed ben-fits of the World Health Organisation (WHO) checklist, aystem for marking the site before removal or exposure ofeeth under general anaesthesia has not been identified.1

We feel that the gold standard for safe removal or expo-

ure of teeth under general anaesthesia should incorporatehe WHO checklist, and include marking of the skin over theurgical site. In our audit we evaluated patients’ preferences

∗ Corresponding author. Tel.: +44 (0)1242 228566;ax: +44 (0)1242 228517.

E-mail addresses: greg.knepil@glos.nhs.uk (G.J. Knepil),aroline.harvey@glos.nhs.uk (C.T. Harvey), andrea.beech@glos.nhs.ukA.N. Beech).

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266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofaciahttp://dx.doi.org/10.1016/j.bjoms.2012.09.010

ith regards to the location of a marking system that is closeo, and correctly oriented to, the site of operation.

We have developed a new system of marking the skinefore oral surgical procedures that involve the extraction orxposure of teeth under general anaesthesia. This system wasntroduced to Gloucestershire Royal Hospital in 2010, aftersuccessful audit of patients’ and clinicians’ experience.

ethod

e recorded clinicians’ and patients’ preferences for the sitef marking the skin, together with personal and operativeata. Two options for the site of marking were the cheeks and

he forehead, or they had the option to refuse marking. Thekin was then marked according to the patient’s preference.

The system for marking on the cheek is shown in Fig. 1,nd is an anatomical adaptation of the Palmer Notation

l Surgeons. Published by Elsevier Ltd. All rights reserved.

414 G.J. Knepil et al. / British Journal of Oral and M

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ig. 1. Marking of the cheek before operation (published with the patient’sermission).

ethod of numbering teeth. It involves the use of a fine-ipped surgical marking pen. Each cheek indicates the uppernd lower quadrants for the corresponding left or right side.line is drawn on each cheek close to the labial commissure

n the direction of the tragus to delineate the upper and loweruadrants. The deciduous or permanent teeth to be extractedhould be drawn in their correct quadrant with the appropriateumber/letter. Supernumerary teeth should be marked with a$” sign, and teeth that are to be exposed should be circled.

hen the procedure has been completed the markings areemoved with an alcohol wipe (SteretTM).

esults

e studied a total of 50 patients. Thirty-six of the respon-ents were adults, of whom 20 were male and 14 female; theemaining 16 were children. Forty-eight chose to be markedn the cheek, 1 preferred to be marked on the forehead, andman refused to be marked. The patient who preferred to bearked on the forehead was a 55-year-old man who stated

hat he felt it would be more visible in this position. Theatient who refused to be marked was a man aged 45 whohought that it was unnecessary. Many of the children clearlynjoyed the application of the skin markings, particularlyhose who had experience of face painting, and consequentlyarents were often asked to take photographs for them to shareith friends. The two clinicians taking part in the audit bothreferred the cheek marking system because it was not cov-red by surgical drapes, was closer to the surgical site, and wasisible throughout the operation. This system was thought toe quick, effective, and easy to understand by members ofhe surgical team who participated in the checklist.

iscussion

atients who have maxillofacial operations are subjecto numerous risks. The concept of Cockpit Resource

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axillofacial Surgery 51 (2013) 413–415

anagement, which evolved from the aviation industry, hasdentified many “human factor errors” which are equallypplicable to the operating theatre, and these principles areow being adopted by the health industry to mitigate thoseisks.2

In 2005, the NPSA and Royal College of Surgeons ofngland jointly released the “Patient Safety Alert: Correctite Surgery”. It stated that skin should be marked at, or near,

he intended site of incision at the correct laterality by theperating surgeon, or nominated deputy, at the time of theperation.

In 2008 the WHO checklist was published as part of theafe Surgery Saves Lives Challenge. Its aim was to min-

mise common and avoidable risks that may endanger theives and wellbeing of surgical patients.3 An important part ofhis checklist is marking of the surgical site, which is requiredhen there is laterality or when multiple organs are involved.Despite this clear guideline, and the fact that teeth have

aterality and are multiple, a system for marking the skin hasot been identified for removal or exposure of teeth undereneral anaesthesia.

A marking system to prevent the removal of the wrongooth has previously been published, which indicates theooth number(s), or marks the site of the tooth or the surgicalite on a diagram or radiograph and is included as part of theatient’s record. This system was ratified by the Americanental Association and the Joint Commission on Accredita-

ion of Healthcare Organizations (JCAHO).4 It is importanto note that this system still does not include marking the skinf the patient near to the operative site, which is a crucial stepn reducing the risks that can arise as a result of disorientationf the operating surgeon.

In the UK removal of the wrong tooth is now classified byhe NPSA as “wrong site surgery” and as such it is treated as“Never Event”, and in the USA it is classified as a “Sen-

inel Event” by JCAHO. The occurrence of a “Never Event”ot only implies that a patient has come to serious harm, butlso there are consequences for the surgeon and organisa-ion. Even if the surgeon thinks that the patient has come too additional harm, there is a professional and ethical dutyf candour to explain this error to the patient.5 The incidentust be reported to the hospital’s risk management system

nd communicated to all those people involved, includinghe patient, the Primary Care Trust (PCT), and the NPSA.n 2010–2011 the National Reporting and Learning SystemNRLS) of the NPSA recorded 400 incident reports of which0 (5%) were extraction of the wrong tooth (Personal com-unication from Ms Fran Watts, Patient Safety Lead, NHSommissioning Board Special Health Authority, formerlynown as the National Patient Safety Agency). Removal ofhe wrong tooth is also identified as a common cause for liti-ation in oral and maxillofacial surgery by the NHS litigation

p to £22,650.6

A large proportion of teeth extracted under general anaes-hetic are for orthodontic purposes, so have no visible signs

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f disease and are involved in a treatment plan that haseen prescribed by the orthodontist, and not the operat-ng surgeon. This requires meticulous transcription of therthodontic treatment plan to the operative site. Another rea-on for removal of the wrong tooth is the surgeon’s positionnd rotational movements, which are often required whenooking at radiographs or medical records. This introduces aisk of disorientation with regards to identifying the lateralityf the teeth being removed.

Since the introduction of this marking system we haveound that patients are in favour of facial marking for safetyeasons before oral surgical procedures. The process ofarking also creates another opportunity for communication

etween the surgeon and the patient to agree on which teethre to be extracted or exposed.

Initially, a number of non-facial sites were considered forarking, which included the neck or arm; we also suggested

he use of wristbands or dog tags. However, in practice thelinicians felt that these methods would be impractical. Mark-ng the neck could be uncomfortable for the patient, and notisible under a south-facing airway or surgical drapes. Mark-ng of the arm, dog tags, and wristbands also have the sameack of visibility when concealed under surgical drapes, aret a greater distance from the surgical site, and require annscrubbed member of the nursing or anaesthetic team toxpose the areas from under the drapes.

The audit of clinicians’ and patients’ preferences for facialarking overwhelmingly favoured marking the cheek. This

egion is ideal as it is visible throughout the operation, andllows regular and repeat checking of the teeth to be involved.ince we have used this method of marking we have not had

ny “Never Events” involving the removal of the wrong toothn our unit. We have also found that it is well-tolerated byatients, surgeons, and other members of the surgical team.

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axillofacial Surgery 51 (2013) 413–415 415

After the results of our audit, we now recommend markingf the skin for all patients who are having teeth removed orxposed under general anaesthesia. We recommend locatinghe marking on the cheeks, with the exception of patients withacial hair for whom marking the forehead is a satisfactorylternative, and we offer to mark up self-conscious patients inhe anaesthetic room out of sight of non-medical staff. Withhis system, 100% compliance with the WHO checklist forafer surgery can be achieved.

onflict of interest

here has been no financial support and there is no conflictf interest.

eferences

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. WHO surgical safety checklist and implementation manual; 2008, avail-able from: http://www.who.int/patientsafety/safesurgery/ss checklist/en/index.html

. Lee JS, Curley AW, Smith RA. Prevention of wrong-site toothextraction: clinical guidelines. J Oral Maxillofac Surg 2007;65:1793–9.

. Shekar V, Singh M, Shekar K, Brennan PA. Clinical negligence and duty

of candour. Br J Oral Maxillofac Surg 2011;49:593–6.

. Gulati A, Herd MK, Nimako M, Anand R, Brennan PA. Litigation inNational Health Service oral and maxillofacial surgery: review of the last15 years. Br J Oral Maxillofac Surg 2012;50:385–8.