Preventable errors by health care workers are widespread and cause significant morbidity and mortality. Wrong site surgery (WSS) is a preventable error that causes harm through both the direct insult of surgery and propagation of the untreated initial problem. WSS also can cause poor patient outcomes, low morale, malpractice claims, and increased costs to the health care system. The estimated median prevalence of WSS across all specialties is 9 events per 1,000,000 surgical procedures, and an institutional study of 112,500 surgical procedures reported 1 wrong-site event, which involved removing the incorrect skin lesion and not removing the intended lesion.1,2
Though the prevalence is low when examining all specialties together, dermatology is also susceptible to WSS.3 Watson and colleagues demonstrated that 31% of intervention errors were due to WSS and suggested that prebiopsy photography helps decrease errors.4 Thus, the American Academy of Dermatology has emphasized the importance of reducing WSS.5 A study by Nijhawan and colleagues found that 25% of patients receiving Mohs surgery at a private single cancer center could not identify their biopsy location because the duration between biopsy and surgery allowed biopsy sites to heal well, which made finding the lesion difficult.6
Risk factors for WSS include having multiple health care providers (HCPs) living remote from the surgery location involved in the case, being a traveling veteran, receiving care at multiple facilities inside and outside the US Department of Veterans Affairs (VA) system, mislabeling photographs or specimens, and photographs not taken at time of biopsy and too close with no frame of reference to assist in finding the correct site. The VA electronic health record (EHR) is not integrated with outside facility EHRs, and the Office of Community Care (OCC) at the VA is responsible for obtaining copies of outside records. If unsuccessful, the HCP and/or patient must provide the records. Frequently, records are not received or require multiple attempts to be obtained. This mostly affects veterans receiving care at multiple facilities inside and outside the VA system as the lack of or timely receipt of past health records could increase the risk for WSS.
To combat WSS, some institutions have implemented standardized protocols requiring photographic documentation of lesions before biopsy so that the surgeon can properly identify the correct site prior to operating.7 Fortunately, recent advances in technology have made it easier to provide photographic documentation of skin lesions. Highsmith and colleagues highlighted use of smartphones to avoid WSS in dermatology.7 Despite these advances, photographic documentation of lesions is not universal. A study by Rossy and colleagues found that less than half of patients referred for Mohs surgery had clear documentation of the biopsy site with photography, diagram, or measurements, and of those documented, only a small fraction used photographs.8
Photographic documentation is not currently required by the VA, increasing the risk of WSS. About 20% of the ~150 VA dermatology departments nationwide are associated with a dermatology residency program and have implemented photographic documentation of lesions before biopsy. The other 80% of departments may not be using photographic documentation. The following 3 cases experienced by the authors highlight instances of how quality photographic documentation of lesions prior to biopsy can improve patient care and save lives. Then, we propose a photographic documentation protocol for VA dermatology departments to follow based on the photographic standards outlined by the American Society for Dermatologic Surgery.9