Skip to main content
Avoiding Medical Errors in Cutaneous Site Identification: A Best Practices Review
University of Massachusetts Medical School Faculty Publications
  • Jessica St. John, University of Massachusetts Medical School
  • Jennifer Walker, Mohs Surgery Unit Group Health
  • Dori Goldberg, University of Massachusetts Medical School
  • Mary E. Maloney, University of Massachusetts Medical School
UMMS Affiliation
Division of Dermatology, Department of Medicine
Publication Date
Document Type

BACKGROUND: Although the field of dermatology has a relatively low incidence of medical errors, dermatologic surgery is a major area where medical errors occur.

OBJECTIVE: The purpose of this article is to catalog the many cutaneous site identification techniques used by practitioners and determine which techniques are most evidence based.

MATERIALS AND METHODS: A comprehensive literature review of cutaneous surgical site identification techniques and medical errors in dermatology.

RESULTS: Wrong-site surgery often occurs because of an inability to identify the surgical site because of factors such as inadequate documentation from referring physicians, well-healed scars obscuring the biopsy site, and a patient's inability to visualize the surgical site. Practitioners use techniques such as photography, dermabrasion, written descriptions using anatomic landmarks, and site identification protocols for surgical site identification.

CONCLUSION: Site identification remains a challenge for dermatologists and is a leading cause of medical errors in this field. Patients are often unreliable in their ability to identify biopsy sites; therefore, practitioners must take a proactive role to ensure that medical errors do not occur. This article provides a thorough description and evaluation of current site identification techniques used in dermatology with the aim to improve quality of care and reduce medical errors.

DOI of Published Version
Dermatol Surg. 2016 Apr;42(4):477-84. doi: 10.1097/DSS.0000000000000683. Link to article on publisher's site
Related Resources
Link to Article in PubMed
PubMed ID
Citation Information
Jessica St. John, Jennifer Walker, Dori Goldberg and Mary E. Maloney. "Avoiding Medical Errors in Cutaneous Site Identification: A Best Practices Review" Vol. 42 Iss. 4 (2016) ISSN: 1076-0512 (Linking)
Available at: