Clinical Review & Education Consensus Statement

Funding/Support: This study was supported by research funds from the Department of Dermatology, Northwestern University. Role of the Sponsor: The Department of Dermatology, Northwestern University, was fully responsible for the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Group Information: The Cutaneous Surgery Consensus Group members were Richard Bennett, MD; Daniel Berg, MD; Diana Bolotin, MD, PhD; Jerry D. Brewer, MD; Basil S. Cherpelis, MD; Daniel B. Eisen, MD; Douglas Fife, MD; Algin B. Garrett, MD; Hayes B. Gladstone, MD; Alysa R. Herman, MD; Conway C. Huang, MD; Eva A. Hurst, MD; Nathaniel J. Jellinek, MD; Shang I. Brian Jiang, MD; Arash Kimyai-Asadi, MD; David Kouba, MD, PhD; Jessica J. Krant, MD, MPH; David R. Lambert, MD; Naomi Lawrence, MD; Barry Leshin, MD; Vicki J. Levine, MD; Alan T. Lewis, MD; Erick A. Mafong, MD; Ian A. Maher, MD; Mary E. Maloney, MD; Michel A. McDonald, MD; Christopher J. Miller, MD; Brent R. Moody, MD; Maureen A. Mooney, MD; Victor A. Neel, MD, PhD; Isaac M. Neuhaus, MD; Keyvan Nouri, MD; David B. Pharis, MD; William Posten, MD; Désirée Ratner, MD; Adam A. Rotunda, MD; Joseph F. Sobanko, MD; Ally-Khan Somani, MD, PhD; Seaver Soon, MD; Melanie Warycha, MD; Carl Washington, MD; Summer R. Youker, MD; and Nathalie C. Zeitouni, MD. REFERENCES 1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in

Wrong-Site Surgery in Dermatology

the United States, 2006. Arch Dermatol. 2010;146(3):283-287. 2. Lichtman MK, Countryman NB. Cell phone–assisted identification of surgery site. Dermatol Surg. 2013;39(3, pt 1):491-492. 3. Watson AJ, Redbord K, Taylor JS, Shippy A, Kostecki J, Swerlick R. Medical error in dermatology practice: development of a classification system to drive priority setting in patient safety efforts. J Am Acad Dermatol. 2013;68(5):729-737. 4. Nemeth SA, Lawrence N. Site identification challenges in dermatologic surgery: a physician survey. J Am Acad Dermatol. 2012;67(2):262-268. 5. Hussain W. Avoiding wrong site surgery: how language and technology can help. Br J Dermatol. 2012;167(5):1186.doi:10.1111/j.1365-2133.2012.11024.x. 6. Starling J III, Coldiron BM. Outcome of 6 years of protocol use for preventing wrong site office surgery. J Am Acad Dermatol. 2011;65(4):807-810. 7. Cao LY, Taylor JS, Vidimos A. Patient safety in dermatology: a review of the literature. Dermatol Online J. 2010;16(1):3. http://escholarship.org/uc /item/75z671jb. 8. Ke M, Moul D, Camouse M, et al. Where is it? the utility of biopsy-site photography. Dermatol Surg. 2010;36(2):198-202. 9. McGinness JL, Goldstein G. The value of preoperative biopsy-site photography for identifying cutaneous lesions. Dermatol Surg. 2010;36(2):194-197. 10. Alcalay J, Alkalay R. Histological evaluation of residual basal cell carcinoma after shave biopsy prior to Mohs micrographic surgery. J Eur Acad Dermatol Venereol. 2011;25(7):839-841.

11. Perlis CS, Campbell RM, Perlis RH, Malik M, Dufresne RG Jr. Incidence of and risk factors for medical malpractice lawsuits among Mohs surgeons. Dermatol Surg. 2006;32(1):79-83. 12. Rossy KM, Lawrence N. Difficulty with surgical site identification: what role does it play in dermatology? J Am Acad Dermatol. 2012;67(2):257-261. 13. Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145(10):978-984. 14. Gawkrodger DJ. Risk management in dermatology: an analysis of data available from several British-based reporting systems. Br J Dermatol. 2011;164(3):537-543. 15. Chuang GS, Gilchrest BA. Ultraviolet-fluorescent tattoo location of cutaneous biopsy site. Dermatol Surg. 2012;38(3):479-483. 16. Elwyn G, O’Connor A, Stacey D, et al; International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ. 2006;333(7565):417. doi:10.1136 /bmj.38926.629329.AE. 17. Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003;15(3):261-266.

Invited Commentary PRACTICE GAPS

Wrong-Site Surgery in Dermatology Sherrif F. Ibrahim, MD, PhD

Dermatologic surgeons are faced with a unique challenge that goes beyond the decision of “right” or “left” when identifying the correct anatomical site for surgery. In many instances, we are expected to identify a 3- or 4-mm biopsy site on a Related article page 550 background of severely actinically damaged skin, confounded by scale, erythema, or scars from previous procedures, and armed only with a biopsy report that says “nose” or “cheek.” For reasons detailed in the article by Alam and colleagues1 in this issue of JAMA Dermatology, uncertainty on the part of the surgeon or incongruity between the patient and the surgeon is an inevitable occurrence. The study provides an excellent decision tree to help dermatologic surgeons navigate these situations in an effort to help minimize wrong-site surgery in dermatology. In my own practice, whether I can see a tumor from across the room or need a dermatoscope to identify it, my first action is to hand a mirror to every patient who is seen 558

Box. Procedures to Minimize Wrong-Site Surgery At the Time of Biopsy

• Photograph all lesions to be biopsied: mark lesion before photography, ensure image is in focus, include anatomical landmarks. • Generate a body map: document precise distances to ⱖ2 distinct landmarks (eg, tragus, lateral canthus, oral commissure). At the Time of Definitive Surgery

• Invoke a standardized time-out procedure for all patients: hand the patient a mirror and have him or her point to the biopsy site, delineate the area with a surgical marking pen, reconfirm the site with the patient. • In the event of uncertainty: remove crust and scale, clean the area with alcohol, visually examine and palpate the area under bright illumination, consider a small biopsy or send curettings for frozen section analysis, contact the referring office for additional information, watchful waiting is always an option.

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Wrong-Site Surgery in Dermatology

Consensus Statement Clinical Review & Education

for surgery and ask him or her to point to where the biopsy was performed. In the vast majority of cases, I have already visually identified the site, and watching the patient’s finger land on this same spot enables surgery to proceed. I then clearly define the area with a surgical pen and again hand the mirror to the patient and ask, “Is this where the biopsy was done?” In the event of any disagreement or ambiguity by the patient or myself, the area is cleaned well with alcohol (this helps reduce scale), crust is gently removed, and the process is repeated under bright illumination. Mohs surgeons have the benefit of a pathology laboratory within the office, and often a small shave biopsy or curettings analyzed by frozen section can confirm the correct location. However, the absence of histologic tumor in either situation is of less value (Box). Despite thorough time-out protocols, a clear photograph is often the only way to convince a dubious patient or an unsure physician. Photography has become inextricably tied to the practice of dermatology, and the ubiquity and low cost of digital cameras and memory storage make it simple to streamline into daily practice. Once an area is identified for biopsy, it should be marked on the skin, and a quick photograph of the ARTICLE INFORMATION Author Affiliation: Department of Dermatology, University of Rochester Medical Center, Rochester, New York. Corresponding Author: Sherrif F. Ibrahim, MD, PhD, Department of Dermatology, University of Rochester Medical Center, 400 Red Creek Dr, Ste 200, Rochester, NY 14623 ([email protected] .rochester.edu).

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patient’s demographic label, followed by one of the lesion, takes only a few seconds. This can be wirelessly uploaded to a central repository and automatically organized by date for easy retrieval if needed at the time of definitive surgery. In some cases, a photograph is of little added value, for instance, if the area was not clearly marked before taking the photograph or if the image is not in focus. Often, supporting documentation comes only in the form of a body map generated from an electronic medical record with a large bullet point marking a biopsy site that is half the size of the diagrammed body part. This is of low usefulness and should not be substituted for a photograph. In all cases, it is best to eliminate reliance on anyone’s memory, whether the biopsying physician, the patient, or the treating surgeon. Despite these efforts, situations will arise when it is simply unclear where a biopsy was performed. In practice, if it is indeed near impossible to identify such a site for a low-risk nonmelanoma skin cancer, then that likely means there is minimal or no residual tumor. In light of reservation on the part of the surgeon and inadequate supporting material to help guide the decision, sometimes the best option is to wait and simply monitor for regrowth. improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus [published online March 5, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2013.9804.

Published Online: March 5, 2014. doi:10.1001/jamadermatol.2013.9798. Conflict of Interest Disclosures: Dr Ibrahim has served as a paid consultant to Genentech, Sciton, and DUSA Pharmaceuticals. REFERENCE 1. Alam M, Lee A, Ibrahimi OA, et al. Cutaneous Surgery Consensus Group. A multistep approach to

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