DOI: 10.1177/25160435231220229 ISSN: 2516-0435

A five-step approach to safer skin surgery

Hayley Smith, Raman Bhutani, Angana Mitra, Victoria Goulden, Walayat Hussain, Rajib Rahim, Claire Machin, Graeme I Stables
  • Health Policy
  • Health (social science)
  • Leadership and Management


Wrong site skin surgery is a never event with implications for patient well-being, in addition to potential medicolegal ramifications. There is no standardised approach to wrong site surgery (WSS) prevention in the United Kingdom. However, the World Health Organisation surgical checklist and NHS England's safety standards for invasive procedures (NatSSIP) have been useful in guiding the direction of change.

Our experience:

We describe our experience over the past decade, detailing five cases of WSS including three wrong site biopsies and two re-excisions of the wrong scar. Each provided a learning opportunity, identifying vulnerabilities in the skin surgery pathway.

Our five-step approach to safer skin surgery:

By reflecting on our experience, we created a simple five-step approach to safer skin surgery which could easily be adopted by other dermatology departments. This includes, developing a Standard operating procedure, requesting a surgical procedure, medical photography, in theatre, and education/governance. Our approach provides a step in the right direction for national standardisation of the skin surgery pathway.

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