Discussion
To prevent and minimize poor outcomes associated with WSS, the health care team should routinely document the lesion location in detail before the biopsy. Many HCPs believe a preoperative photograph is the best method for documentation. As demonstrated in the third case presentation, photographs must be taken at a distance that includes nearby anatomic landmarks for reference. It is suggested that the providers obtain 2 images, one that is far enough to include landmarks, and one that is close enough to clearly differentiate the targeted lesion from others.10
Although high-resolution digital cameras are preferred, mobile phones also can be used if they provide quality images. As phones with built-in cameras are ubiquitous, they offer a quick and easy method of photographic documentation. St John and colleagues also presented the possibility of having patients keep pictures of the lesion on their phones, as this removes potential privacy concerns and facilitates easy transportation of information between HCPs.10 If it is discovered that a photograph was not taken at the time of biopsy, our practice contacts the patient and asks them to photograph and circle the biopsy site using their mobile phone or camera and bring it to the surgery appointment. We propose a VA protocol for photographic documentation of biopsy sites (Table).
HCPs who are not comfortable with technology may be hesitant to use photographic documentation using a smartphone or camera. Further, HCPs often face time constraints, and taking photographs and uploading them to the EHR could decrease patient contact time. Therefore, photographic documentation presents an opportunity for a team approach to patient-centered care: Nursing and other medical staff can assist with these duties and learn the proper photographic documentation of biopsy sites. Using phone or tablet applications that provide rapid photographic documentation and uploading to the EHR also would facilitate universal use of photographic documentation.
If a HCP is uncomfortable or unable to use photography to document lesions, alternative strategies for documenting lesions exist, including diagrams, anatomic landmarks, ultraviolet (UV) fluorescent tattoos, and patient identification of lesions.10 In the diagram method, a HCP marks the lesion location on a diagram of the body preferably with a short description of the lesion’s location and/or characteristics.11 The diagram should be uploaded into the EHR. There are other methods for documenting lesion location relative to anatomic landmarks. Triangulation involves documenting distance between the lesion and 3 distinct anatomic locations.10 UV fluorescent tattooing involves putting UV tattoo dye in the biopsy site and locating the dye using a Wood lamp at the time of surgery. The lamp was used in a single case report of a patient with recurrent basal cell carcinoma.12 Patient identification of lesions by phone applications that allow patients to track their lesion, a phone selfie of the biopsy site, or a direct account of a lesion can be used to confirm lesion location based on the other methods mentioned.10
Patients often are poorly adherent to instructions aimed at reducing the risk of WSS. In a study that asked patients undergoing elective foot or ankle surgery to mark the foot not being operated on, 41% of patients were either partially or nonadherent with this request.13 Educating patients on the importance of lesion self-identification has the potential to improve identification of biopsy location and prevent WSS. Nursing and medical staff can provide patient education while photographing the biopsy site including taking a photograph with the patient’s cell phone for their records.
Due to subsequent morbidity and mortality that can result from WSS, photographic confirmation of biopsy sites is a step that surgeons can take to ensure identification of the correct site prior to surgery. Case 1 provides an example of how photographs taken prior to biopsy can prevent WSS. In a disease such as melanoma, photographs are particularly important, as insufficient treatment can lead to fatal metastases. To increase quality of care, all available photographs should be reviewed, especially in cases where the pathology report does not match the clinical presentation.
If WSS occurs, HCPs may be hesitant to disclose their mistakes due to potential lawsuits, the possibility that disclosure may inadvertently harm the patient, and their relative inexperience in and training regarding disclosure skills.14 Surgeons who perform WSS may receive severe penalties from state licensing boards, including suspension of medical license. Financially, many insurers will not compensate providers for WSS. Also, many incidents of WSS result in a malpractice claim, with about 80% of those cases resulting in a malpractice award.15 However, it is important that HCPs are open with their patients regarding WSS.
As demonstrated in case presentations 2 and 3, having 2-person confirmation and patient confirmation before to surgery is important in preventing WSS for patients who have poor documentation of biopsy sites. In cases where agreement is not achieved, HCPs can consider several other options to help identify lesions. Dermabrasion and alcohol wipes are options.10 Dermabrasion uses friction to expose surgical sights that have healed, scarred, or been hidden by sun damage.10 Alcohol wipes remove surface scale and crust, creating a glisten with tangential lighting that highlights surface irregularities. Anesthesia injection prior to surgery creates a blister at the location of the cancer. This is because skin cancer weakens the attachments between keratinocytes, and as a result, the hydrostatic pressure from the anesthesia favorably blisters the malignancy location.10,16
Dermoscopy is another strategy shown to help identify scar margins.10,17 Under dermoscopy, a scar demonstrates a white-pink homogenous patch with underlying vessels, whereas basal cell carcinoma remnants include blue-gray ovoid nests and globules, telangiectasias, spoke wheel and leaflike structures.17 As a final option, HCPs can perform an additional biopsy of potential cancer locations to find the lesion again.10 If the lesions cannot be identified, HCPs should consider conservative measures or less invasive treatments with close and frequent follow-up.
Conclusions
The cases described here highlight how the lack of proper photographic documentation can prevent the use of curative surgical treatment. In order to reduce WSS and improve quality care, HCPs must continue to take steps and create safeguards to minimize risk. Proper documentation of lesions prior to biopsy provides an effective route to reduce incidence of WSS. If the biopsy site cannot be found, various strategies to properly identify the site can be employed. If WSS occurs, it is important that HCPs provide full disclosure to patients. With a growing emphasis on patient safety measures and advances in technology, HCPs are becoming increasingly cognizant about the most effective ways to optimize patient care, and it is anticipated that this will result in a decrease in morbidity and mortality.