Published 5/1/2013
David C. Ring, MD, PhD

Confirm Before You Cut

For surgical safety, confirmation is key

Six critical components of surgical safety have been identified by Calvin C. Kuo, MD, and William J. Robb III, MD. These ‘Critical Cs of Surgical Safety’ include the following:

  • Consent—accurate and timely informed surgical consent
  • Confirmation—timely and correct surgical patient/site/procedure identification
  • Communication—effective, transparent patient and surgical team communication
  • Consistency—regular use of standardized, validated evidence and/or consensus-based surgical processes such as checklists
  • Concentration—focused patient, surgeon, and surgical team interactions without distractions
  • Collection—timely and systematic safety data accumulation and analysis

If followed, these six critical Cs can minimize surgical harm. In previous articles, the AAOS Patient Safety Committee has addressed consent and concentration; this article addresses confirmation.

Confirm the patient
It all starts with having the correct patient. According to data from the Joint Commission (2006), 17 percent of wrong-site surgeries were surgeries performed on the wrong patient.

Every physician has had the experience of calling a patient from the reception area and the wrong patient answers the call to the exam room. Whether it’s a language barrier, hearing impairment, or similar names, this happens. Sometimes the wrong patient is sent for a radiograph, which entails some risk and inconvenience. Even with electronic medical records, information and scanned consent forms may inadvertently be placed in the wrong patient’s record.

Read backs using two identifiers (eg, name and birth date or medical record number) can help mitigate this situation. When the patient rises to enter the exam room or to get a medical record, the medical assistant or healthcare provider can read the patient’s name and birth date, confirming that the patient who is present is the correct patient.

In the operating room
Operating on the wrong patient can be eliminated by taking time to confirm that the patient on the table is the correct patient. Any orthopaedic surgeon who works in an efficient operating room has had the experience of scrubbing for surgery and walking into a room to find the patient already draped. Perhaps all that is visible is an arm or a leg. If the order of cases has changed, if the surgeon is otherwise unprepared, or if a mix-up in paperwork or equipment has occurred, an error can be made.

According to the World Health Organization’s Surgical Safety Checklist, patient identification is the first part of both the sign-in and the time-out after team introductions. A helpful strategy may be to use identification bands that cannot be removed and that the patient wears until he or she leaves the hospital.

The Canadian Orthopaedic Association introduced the “operate through your initials” initiative in 1994, instructing orthopaedic surgeons to mark the incision site with their initials so that they would have to cut through them to do the surgery. In this way the ink acts as a bull’s-eye, drawing the surgeon’s attention to the correct surgical site. The corresponding campaign by the AAOS is “Sign your site.”

Unfortunately, not all orthopaedic surgeons readily adopted these measures. Some had unfounded concerns about infection due to the ink, or disruptions when planning the incision, or even fears that the patient might lose confidence in them. I can remember feeling silly when asking the patient to tell me what surgery I was to perform. Thankfully, those days are long gone and patients expect to be asked repeatedly who they are and what they are having done. Surgeons and patients now feel uncomfortable if these questions aren’t asked and sites aren’t signed.

Lots of choices, chances for error
Orthopaedic surgery is particularly prone to wrong-site surgery, given multiple limbs and digits, not to mention the difficulty in identifying the correct spinal levels, particularly when deformity exists. In a survey study, 21 percent of hand surgeons reported performing at least one wrong-site surgery. Not only must hand surgeons be concerned about multiple digits, but also multiple different sites where surgery is common.

Permanent ink should be applied with the patient’s assistance prior to surgery to limit the risk of wrong-procedure or wrong-site surgeries. To ensure the correct spine level, the North American Spine Society recommends “Sign, Mark, and X-ray” because the level is not always visually identifiable and should be confirmed radiographically.

Keep confirming
The procedure should be confirmed after draping and just prior to the incision, during the time-out. The surgeon should read the procedure directly from the consent form. If the surgery involves multiple parts, each part should be numbered on the consent form, each should be separately stated during the time-out, and each should be confirmed at the sign out at the end of the procedure.

In joint reconstruction procedures, the proper implant of the proper side and size should be confirmed before being placed. Implants that are opened individually during the procedure are confirmed by the entire surgical team prior to opening the package by reading directly from the package. The type, side, and size of each implant from a complete open set (eg, plates and screws) should be confirmed individually as each is requested by the surgeon.

Many orthopaedic procedures include parts that need to be removed before closing the incision. These can include wires inserted as guides or markers, drill guides that are incorporated on plates, and retractors. These parts should be added to the count list; the count list should be read back and verified before closing the wound. The entire surgical team should be involved in ensuring that everything that should come out is removed.

All members of the surgical team should feel valued and encouraged to speak up. It is the responsibility and the ability of each team member to catch human error before it becomes harm.

David C. Ring, MD, PhD, is a member of the AAOS Patient Safety Committee. He can be reached at dring@partners.org


  1. Kuo CC, Robb WJ 3rd: Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety. Clin Orthop Relat Res 2012 Dec 6.
  2. Wong DA, Lewis B, Herndon J, Martin C Jr, Brooks R: Patient safety in North America: Beyond “Operate Through your Initials” and “Sign Your Site.” J Bone Joint Surg Am 2009;91(6):1534-1541.
  3. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5):491-499.
  4. Johnston G, Ekert L, Pally E: Surgical site signing and "time out": Issues of compliance or complacence. J Bone Joint Surg Am 2009;91(11):2577-2580.
  5. Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am 2003;85-A(2):193-197.
  6. Bhattacharyya T, Wadgaonkar AD: Inadvertent retention of angled drill guides after volar locking plate fixation of distal radial fractures: A report of three cases. J Bone Joint Surg Am 2008;90(2):401-403.
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Other articles in this series:
Robb WJ, Carroll D, Kuo C.
Orthopaedic Surgical Consent: The First Step in Safety. AAOS Now, February 2013

Wilkinson JB. Concentration: A double-Edged Sword? AAOS Now, April 2013