Summary: Patient Safety Considerations

•The preoperative evaluation is an important part of Mohs surgery.

•Key parts of the medical record are best verified for accuracy prior to surgery.

•A detailed preoperative history and physical exam can uncover important patient safety issues.

44.2Patient Safety Considerations

The first step of ensuring patient safety during Mohs surgery is the preoperative evaluation. The preoperative visit provides an ideal venue for the physician to evaluate a patient’s overall health status, screen for any conditions that pose a threat to safe execution of the surgery or recovery from the procedure, and educate the patient about his or her role in Mohs surgery. By establishing rapport during this visit, the Mohs surgeon can bring the patient into the “team” thereby helping to enhance outcomes and simultaneously screen for any comorbidities that pose safety issues before, during, or after surgery.

44.2.1 The Preoperative Visit

In a busy Mohs surgical practice, it is tempting to view the preoperative visit as a mere formality and rush through it on the way to more “important” or lucrative work. However, this would not be advisable, as, by doing so, one could miss a critical first step in planning for a successful outcome. In the authors’ experience, mistakes occur when assumptions are not verified. Here, it is best to follow the proverb made famous by President Ronald Reagan: “Trust but verify.”

For instance, physicians, staff, and patients typically assume that prior medical records are correct and complete. However, it is not uncommon for seasoned Mohs surgeons to tell of multiple instances of inconsistencies in patients’ accompanying medical records, such as conflicting information on the anatomic site of the cancer or the type of cancer itself.

Whether the Mohs surgeon is dealing with a preexisting patient or a referral from a colleague, it is a

good habit to assemble the prior records prior to surgery and assess them for accuracy and consistency. In Mohs surgery, a prior biopsy has almost always been done. It is very helpful if the pathology report is present at the preoperative visit, and, if so, the date of biopsy and site of biopsy should be verified with the patient. Again, it is best to trust the report, but nonetheless verify with the patient the most pertinent facts. The authors find it useful to hand the patient a mirror and ask the patient to point out where the biopsy was performed. This spot is marked and matched against the spot indicated on the pathology report and any chart notes or photographs. This step helps in identifying and correcting possible errors in previous charting. If an error is located or a patient indicates a site different from that supported by the records, additional information is often requested from the referring physician and the inconsistency cleared before proceeding. By adhering to these principles whenever possible, the authors have identified and corrected charting and lab errors that could have potentially resulted in wrong-site and wrong-diagno- sis surgery.

44.2.2Past Medical History and Physical Exam

Another key step in the preoperative evaluation is taking a detailed history and physical exam. Granted, Mohs surgery has a very low incidence of complications. In fact, a recent evaluation by Cook and Perone reported the incidence of complications associated with Mohs to be 1.64% [1]. However, as anyone doing Mohs can attest, it is definitely not risk-free. In the process of performing a thorough history and physical, the surgeon can identify factors that pose real or potential safety issues. For instance, patients may have sensitivities to local anesthetics, have conditions that inhibit proper wound healing, have risk factors for infection, or be on medications that predispose them to bleeding or inhibit appropriate immune responses.

These, and other topics, frequently come up in the course of discussing a detailed past medical history. Patients are then given information and specific recommendations to help plan for a successful surgical outcome. The following is information useful to patient education and surgical planning.