I first learned about the problems with our timeouts the hard way. Soon after we implemented our timeout initiative, our internal QA committee reported 100 percent compliance. But when I shared the good news with our surgery executive board, my elation turned to deflation.

It turns out that there was a good deal of laxness across the continuum of this quick yet vital protocol. Some surgeons and anesthesia staff were either indifferent toward the process or weren't even aware that this safety protocol was taking place. "I've never heard a timeout being called in my room" remarked one surgeon. How could there be such a variance from the QA data and what I was hearing at this meeting?

There obviously wasn't equal support and buy-in from the entire team. Some of the nurses didn't enforce team compliance. Instead, they held a timeout independent of the rest of the team and then would document on the chart that a timeout had occurred. The further breakdown in this protocol came with the surgical techs not wanting to squeal on their nurses. So the false 100 percent figure became official. Uncovering the truth stung a bit; I felt like the child who'd been sent to timeout.

I began my own investigation and was shocked to discover our executive board was correct. Our timeout-compliance rate was closer to 40 percent. Our scores are now consistently 100 percent with documented evidence to support a timeout before incision. Here's how we did it.

Striving for consistency
One important focus where we discovered inconsistency throughout the OR was which member of the surgical team took the initiative to call the timeout. Sometimes it was the anesthesiologist, sometimes the surgeon, sometimes the nurses.

Of greater concern was the fact that circulating nurses were documenting on the electronic operative record that timeouts were performed, when that wasn't completely true. In order to qualify as an accurate timeout, the entire surgical team present must actively and orally participate in the process. In truth, it was discovered that due to non-compliance or indifference toward participation, some nurses simply conducted the timeouts by themselves, with little or no participation from the surgeons or anesthesia staff present. We only discovered this after we validated, observed and measured timeouts for a two-week period. Results, in fact, demonstrated that no structured timeout had been called in 38 percent of the cases.

To get our timeouts back up to a true 100 percent standard, we developed and implemented a structured timeout checklist that we would post on the door in every OR suite. The timeout list requires checking

• the patient's identity (check the ID band and the patient's date of birth),
• correct side and site (make sure it's been marked with the surgeon's initials in advance),
• the procedure to be performed,
• correct patient position, and
• correct implants and special equipment or requirements as required by national standards.

Our list also required expectation of pathology specimens and validation of pre-op antibiotics (given within one hour of cut time and documentation of such).

We prioritized the fact that one individual must be responsible for initiating the timeout. In our case, we chose the circulating nurse, based on specific factors with our university-based department. At a private hospital or outpatient surgery center, circulating nurses are so busy I might be reluctant to add to their burden. I might suggest the surgeon as the caller of the timeout at an ASC. The point is to be consistent.

Oral confirmations
Timeouts must be proactive and participatory. We require a spoken response from each team member - circulator nurse, surgeon, anesthesia, scrub technologist and any additional ancillary staff present during the case. For example, at our hospital, the nurse would call for the correct patient identity, and both the anesthesiologist and the surgeon would verbally state confirmation. The nurse would call out the correct site and procedure, and the surgeon/team would again orally confirm, and so forth. We of course resolve any confusion or discrepancy before proceeding through the entire process.

We found the best time to perform a timeout is before induction or sedation. Keep in mind that the patient as an active participant may be invaluable as an additional means to confirm required safety information.

In the pre-op/holding area, we conduct an informal timeout to identify correct patient, allergies, blood bands, consents (surgical and anesthesia), correct sites with initials and completion of all pre-op screening requirements. Nurses confirm identity by visualizing the name band at the exact time the patient and family say the patient's name and date of birth. We chart this information on the electronic pre-operative record, which lets the operative team view it before the patient arrives in the surgical suite. However, this never takes the place of a structured timeout that incorporates the entire operative team before sedation or analgesia.

Success factors
Here are a few keys to timeout success:

• Perseverance. Don't expect instant success.
• Doc figureheads. Incorporate a surgeon- and anesthesiologist-champion into your plans.
• Evangelize. Look outside your department for liaisons who'll promote your cause (such as the office of clinical effectiveness, crew trainers and nurse educators).
• Let them see it. Post a standardized timeout checklist in every OR so the entire team can follow a structured plan universally.

Once you meet consistent success, roll out a facility-wide timeout program, complete with yearly competencies each OR employee must complete. A video of the timeout processes in both pre-op holding and OR completes this program. We also include a test.

Nine months after we implemented timeouts for surgery services, our compliance rate reached 100 percent. And this time it was for real.