Minnesota Hospital Association

Quality & Patient Safety

April 22, 2010

Minnesota Patient Safety Alert: Site marking not located prior to procedure start


The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted that in 38 percent of wrong site procedures reported since October 2009, the correct site was marked by the person performing the procedure, however, the site mark was not located, and its location shared with the procedure team, as part of the time-out process. Root cause analyses reviewed indicate that in most cases the site mark was not visible after prepping and draping and the team proceeded with the procedure without looking for and locating the site mark.


Marking the site of a surgical or invasive procedure prior to initiation of the procedure is a crucial step in the verification process. However, if that site mark is not visualized during the time-out process, the value of this step is undermined and the final opportunity to prevent a wrong-site or wrong procedure incident may be missed. The community standard for time-out in Minnesota includes visualization and verbal confirmation of the site mark by a member of the operative team as part of a robust, active time- out process. 

MHA and MDH recommend that facilities revisit their surgical and other invasive procedure policies and processes to clarify responsibilities for locating the site marking prior to procedure start as part of the time-out process.  It is also recommended that observational audits be performed to observe whether or not this step of the process is being completed on a consistent basis.

The Minnesota time-out recommendations include the following steps:

  • Surgeon: Initiates the time-out 4  
  • Circulator: Reads aloud the patient’s name, 2nd identifier, procedure and procedure site from the informed consent document that has been previously verified during pre-op and asks the team to verify.
  • Anesthesia Care Provider: States patient’s name, 2nd patient identifier and procedure (can be short-hand version of the procedure) with laterality if appropriate.
  • Scrub Person: 1st – Verifies which procedure they have prepped — can be a shorthand version of the procedure; 2nd – Visualizes the mark, verbally indicating that he/she sees the mark and where it is located.
  • Surgeon: States full procedure; asks scrub person to remove the time-out towel to begin the procedure.