A Critical Catch: How One Time Out Protected a Patient from Harm

“If we hadn’t stopped and checked, we could’ve operated on the wrong side.”

For Kristyn Seeman, MLS, BSN, RN, CNOR, a former OR nurse and now a senior clinical perioperative research librarian at AORN, the moment is still crystal clear.

She had just stepped in as the relief nurse when she began reviewing the case. Everything looked routine—until the patient said something that didn’t match the paperwork.

Everything Looked Routine—Until the Time Out

“The patient told me she was having surgery on her right breast,” Seeman said. “But when I looked at the consent, it said left.”

It was during the surgical Time Out—a moment when the whole team pauses to confirm key details—that Seeman’s concern came to light. The patient was still awake and alert, and Seeman called the surgeon into the room.

“I said, ‘This doesn’t match,’ and they took it seriously,” she said. “The surgeon came in, confirmed the correct site with the patient, fixed the consent, and everyone initialed it. Then we moved forward. We caught it before any harm could happen.”

What stood out most to Seeman wasn’t just the near miss, but the way her team responded. 

“Nobody got defensive. There was no blame. Everyone focused on protecting the patient. That’s what the Time Out is supposed to do,” she said. 

Established 21 years ago by AORN in collaboration with The Joint Commission, National Time Out Day is observed each June to remind surgical teams of the power of the pause. It’s a moment to stop, verify, and speak up—a critical last checkpoint that ensures the right procedure is performed on the right patient, at the right site.

“It’s probably our highest priority as perioperative professionals,” said Dr. Lisa Spruce, DNP, RN, ACNS, ACNP, CNOR, FAAN, AORN’s Director of Evidence-Based Perioperative Practice. “It’s your final opportunity to keep your patient safe.”

Even though the Time Out has become a routine step, the stakes remain high. In fact, wrong-site surgeries increased by 26% in 2023.

Why?

“My guess? People are rushing. Maybe skipping steps. Or maybe they’re not using the checklist in a meaningful way,” Dr. Spruce said. 

The solution, she says, is personal ownership and team buy-in. 

“When periop teams create their own Time Out process, it means more. It’s not just a box to check—it’s theirs,” she said.

Dr. Spruce also believes everyone in the surgical scheduling and prep chain should be part of the safety net—from schedulers to the surgical team. “Standardizing that process across the board is how you catch things early,” she said.

Speaking Up Isn’t Always Easy—But It’s Always Worth It

Seeman agrees that confidence and communication are key. “You’ve got to go to sleep at night, and your license is on the line,” she said. “You’re accountable for speaking up—and you owe it to the patient.”

Dr. Spruce echoed the importance of creating a supportive culture that empowers every team member to voice concerns. “I know what it’s like to be intimidated in the OR,” she said. “But no one else is going to speak for that patient—only you. You have to find your voice.”

Her advice? 

Practice speaking up in scenario-based training and keep the focus on the patient. “Find a narrative that works for you. Something like, ‘I’m not comfortable moving forward until we confirm this.’ When it’s about the patient, people are more likely to listen.”

Time Out Day Highlights a Habit Worth Building—For New and Veteran Nurses Alike

Despite how routine it may seem, even experienced teams can make mistakes if they skip the pause. Dr. Spruce recalled a moment when her team had already draped the patient—only to realize during Time Out that it was the wrong leg.

“If we hadn’t stopped, we would have proceeded on the wrong side. That’s how easily these things can happen,” she said.

And for new nurses just starting out, building confidence to speak up during the Time Out is equally essential. It begins with support, practice, and developing a clear, respectful way to raise concerns.

Seeman stresses that a simple pause can protect everyone in the room—not just the patient, but the entire surgical team.

“We all came together to fix it,” she said. “That’s what I remember most. The collaboration. The focus. The fact that the patient never even knew how close we came to a serious error. That’s the kind of team you want to be a part of.”

They agree that in two minutes, you can prevent a tragedy. You can protect your patient. And you can speak up for someone who can’t.

Learn More About Time Out Day

Time Out Day falls on June 11, 2025. Learn more here.