A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and documented as "left cheek" in the health record. The second biopsy was consistent with an atrophic solar keratosis (a benign finding) and the site was documented as "left inferior orbit."
The patient was then referred to a dermatologic surgeon to have his SCC excised. The accompanying referral documentation included a diagram of a face with the SCC biopsy site marked by an "X" on the left cheek. The pathology report included a description of the anatomic location that was also noted as "left cheek." On the day of surgery, standard preprocedure verification was completed. The surgery site was marked after the patient confirmed the biopsy site with use of a mirror, two physicians identified a biopsy scar within a clinical lesion on the left cheek, the diagram from the referring physician was reviewed, and the anatomic description of the site from the pathology report was confirmed. The surgeon then excised a lesion on the left cheek.
The patient returned to his referring physician, who immediately realized that the wrong lesion (the benign solar keratosis) had been excised. The patient returned to the surgeon to report the mistake. On closer review, he realized that the actual site of the SCC was, while nominally on the left cheek, more specifically near the preauricular skin. The lesion excised was the one referred to as "left inferior orbit" rather than "left cheek"—an error that resulted from ambiguity in the description and the patient's self-identification of the wrong lesion. The patient required a second surgical excision to remove the SCC lesion.
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