In 1999, the Institute of Medicine’s (IOM) first report, “To Err Is Human”, brought forth the issue of medical error in patient care.1 In this publication, the IOM recognized that mistakes or failures to prevent mistakes were mostly caused by flawed systems, processes, and conditions. It outlined a four-tiered approach to improve safety including: 1) development of leadership, research, tools, and protocols to enhance the knowledge base on safety, 2) a nationwide public mandatory reporting system and encouraging voluntary participation to identify and learn from errors, 3) oversight organizations, professional groups, health care purchasers to raise performance standards and expectations, and 4) implementation of safety systems in the healthcare organization to ensure delivery of safe practice. This was the first roadmap towards a safer health system.
Surgical specialties have incorporated Universal Protocol, consisting of a verification process, surgical site marking, and time out immediately prior to procedure. The time out is designed to ensure correct patient identity, correct scheduled procedure, and correct surgical site. The pre-procedure verification process and surgical site marking include the patient, nursing staff, and Mohs surgeon by confirming patient’s name and date of birth, reviewing pathology report and photographs if available, and involving the patient in site identification. We believe a time out process during interpretation of Mohs histopathology sections would minimize mapping errors that could lead to persistence or recurrence of cancer, as well as over-resection of tissue.