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4 Keys to a Better Time Out, Now

Publish Date: 5/15/2013

Do you know your risks for wrong site surgery? Current stats* from the Joint Commission Center for Transforming Healthcare offer a chilling reminder of how prevalent wrong site surgeries (WSSs) are and how simple errors introduced at any point in a patient’s perioperative experience can open the door for WSS…

  • 1,300-2,700 WSSs occur annually in the U.S.
  • 40-60 WSSs likely occur in the U.S. each week
  • 85% of WSSs analyzed had inadequate planning
  • 72% of WSSs analyzed had defects in the "Time Out"

"Wrong site surgeries are massively underreported. Don’t assume you have good processes because you haven’t had a wrong site surgery," cautions Coleen Smith, RN, MBA, CPHQ, High Reliability Initiatives Director for the Joint Commission Center for Transforming Healthcare.

"As the patient’s advocate, perioperative nurses have the right and the responsibility to be on guard for anything that is off and to speak up before that scalpel penetrates a patient’s skin," Smith stresses. "We see how the simplest errors combined with a lack of standardized safety checks can leave a patient vulnerable for wrong site surgery."

Recognize the risks

Through initial work from hospitals participating in the Reducing the Risk of WSS project, the Joint Commission Center for Transforming Healthcare has discovered that many process errors associated with WSS are linked to the Time Out, including:

  • Inconsistent or absent Time Out process for regional blocks
  • Distractions and rushing during Time Out
  • Time Out process occurs before all staff are ready or before prep and drape occurs
  • Time Out performed without full participation
  • Time Outs do not occur when there are multiple procedures performed by multiple providers in a single operative case

Although consistently safe practices are the result of coordinated team efforts, Smith says perioperative nurses have the power to prevent wrong site surgeries today.

Here are the top 4 ways she suggests perioperative nurses can improve Time Out practices immediately:

  1. Model ideal behavior and coach peers
    Too often teams don’t know what a good Time Out looks like. Show them. Speak up and ask for activity to be stopped so all team members actively participate in the Time Out.
  2. Reward safety
    Safety always takes precedent over production. Nurse leaders (and physician leaders) must be clear about this. Role-specific characteristics built into Time Out practices should also be built into job evaluations so safety actions are linked to merit.
  3. Don’t allow deviation from the standard Time Out
    Follow standardized Time Out practices every time. Don’t allow individual surgeons to perform it differently. If a surgeon tailors the Time Out, you are taking out the standardization and thus the safety—weakening the system every time you do it.
  4. Be watchful for inconsistencies and voice concerns
    Take time to listen to patients/family and compare against documentation. Be constantly on guard for inconsistencies and other warning flags that pop up through the patient’s entire perioperative experience. Most importantly, voice your concerns—by not communicating to others you are eliminating the ability of the team to prevent WSS from occurring.

Make today the time for change

June 12 is National Time Out Day, but practicing a consistently high quality Time Out should be a daily effort. As part of ongoing work to eradicate wrong site surgery, AORN and The Joint Commission are partnering to stress the use of two tools (one from each organization) that teams can use to improve Time Outs and other safe practices proven to shield patients from WSS.

From The Joint Commission: The Targeted Solutions Tool™ (TST) helps individual perioperative teams identify WSS risks. The tool also helps teams choose solutions based on these risk points, in order to shore up processes and prevent these risks from exposing a patient to the chance for wrong site surgery.

From AORN: The AORN Comprehensive Surgical Checklist incorporates recommendations from The Joint Commission and the World Health Organization to prevent WSSs. The checklist addresses:

  • Pre-procedure check-in in the surgical holding area
  • Sign-in before induction of anesthesia
  • Time Out before skin incision
  • Sign-out before the patient leaves the operating room

AORN also has a comprehensive Time Out webpage with links to a number of tools and information on preventing wrong site surgery and building a strong safety culture.

*Statistics on wrong site surgery from the Joint Commission Center for Transforming Healthcare were shaped by a third party, based on data from selected states that require reporting of adverse events and that publish their data.

Additional Resources

Joint Commission Center for Transforming Healthcare 

Guidelines for Perioperative Practice


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