Wrong Surgeries Up 26% in 2023


June 12 is National Time Out Day

Pause to Prevent Wrong Surgeries

Reported wrong site, wrong procedure, wrong patient and wrong implant surgeries increased 26% in 2023, according to new numbers from The Joint Commission’s Sentinel Event Data 2023 Annual Review. Leading contributors to wrong surgeries cited in the report include:

  • No or insufficient Time-Out procedures
  • Preoccupation/task fixation limiting situational awareness
  • No or inadequate shared understanding among team members

Your Time Out is about more than data, it’s about the process of making sure every team member has the chance to speak up with concerns that could impact patient safety.

Time Out was first introduced with the Universal Protocol in 2004. As the twentieth anniversary of this essential pause before incision approaches, AORN recommends reviewing and seeking ways to improve your OR team’s communications. National Time Out Day is June 12, 2024. Use this time to strengthen your Time Out process to ensure safe surgery for every patient, every time.

Here’s the latest evidence on best practices for Time Out and other team communications in surgery from AORN Senior Director of Evidence-Based Perioperative Practice Lisa Spruce, DNP, CNOR, CNS-CP, FAAN. She recently co-authored the 2024 update to the Team Communication guideline.

What causes wrong surgery?

In Dr. Spruce’s recent research, she found that a significant number of adverse events in the OR are caused by system factors and non-technical elements of surgery. These include:

  • Communication
  • Team dynamics
  • Interaction with tools and technology
  • The physical environment

What are the best ways to reduce adverse events?

Key communication tools recommended by AORN in the Team Communication guideline include:

  • Time Out—This is the final step in The Joint Commission’s Universal Protocol, preceded by the pre-procedure verification and the surgeon marking the procedure site. Today it remains part of the National Patient Safety Goals® chapter of The Joint Commission accreditation manual.
  • Surgical Safety Checklist—First released in 2007 by the World Health Organization, this checklist establishes a structured dialogue around three key phases in surgical care—before induction of anesthesia, before incision, and before the patient leaves the OR.
  • Comprehensive Surgical Checklist —AORN combined elements from The Joint Commission’s Universal Protocol and the World Health Organization’s Surgical Safety Checklist to create this comprehensive tool. It includes dialogue for four phases in surgical care—preprocedural check-in, sign-in, Time Out, and sign-out.

Other evidence-based safety practices teams use to reduce adverse events include:

  • Team members addressing each other by name
  • Hierarchical barriers diminished
  • Sufficient staffing resources
  • Shared understanding of teamwork
  • Familiarity among members
  • Inclusive leadership

How can teams assess their Time Out for improvement?

Evaluating the Time Out process is important. It can help identify ways to improve how team members speak up for the patient and address their concerns.

Dr. Spruce suggests that teams working to improve their Time Out should focus on:

  • Standardizing the Time Out process—standardization improves effectiveness.
  • Involving all members of the perioperative team.
  • Designating one team member to call for the time out.
  • Stopping all unnecessary activities and conversations when the Time Out is called.
  • Discussing any patient safety concerns or concerns about the procedure during the Time Out.

What does a good Time Out look like?

According to nurse leader Jessica Havens, BAN, RN, who oversees communication processes across ORs at Seattle Children’s Hospital, the Time Out remains a very structured “challenge and response” process.

This is when they first implemented a highly standardized process for the Time Out that includes these steps:

  • After induction and before the patient is prepped, the nurse asks if everyone is ready for Time Out. Everyone must say “yes,” otherwise they wait.
  • For the Time Out the nurse asks questions that a designated person answers. Questions address each member of the team including nurse, surgeon, scrub tech, and anesthesia team member.
  • Large posters with the Time Out questions are displayed on the OR wall for all team members to see and follow. Each team member’s question is color-coded to ease visibility.

“Everyone has a voice and a portion of the Time Out, so everyone is engaged,” Havens notes. Beyond answering questions, anyone can speak up during the Time Out. For example, if the surgeon has no concerns about deep vein thrombosis but the anesthesiologist thinks differently, there is an expectation that the anesthesiologist (or anyone else in the room) should speak up.

They use a similar “challenge and response” list of questions for preprocedural verification and at the end of the procedure. Each “challenge and response” process, including the Time Out, is mandatory in practice and in documentation, Havens explains. She says outpatient surgery teams follow the same processes.

Despite this all running smoothly, Havens and her team still catch things in the Time Out that were missed in preprocedural verification. “That’s why it’s really great to have this challenge and response because it engages everyone in the room.”

Beyond patient safety, their Time Out process also promotes teamwork. “It’s great to see how our Time Out helps the patient and the team by giving everyone the sense they are valued and heard.”

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