SEE SOMETHING, SAY SOMETHING Only about one-third of survey respondents say physicians always encourage OR staff to speak up if they have concerns.

Maybe the best way to get physicians to fully engage in surgical time outs is to turn up the volume. Literally. At one Texas facility, "the procedure doesn't start until a loud time out with all staff fully engaged takes place," says an assistant nurse manager. "Our physicians are totally engaged with our time outs [because] the question is asked loudly: 'Does everybody agree?'"

Why not belt it out, if that's what it takes? After all, virtually everybody in health care agrees that patient safety is — or at least should be — paramount. Our latest reader survey underscores the dedication and tireless work facility leaders are putting in toward keeping their patients safe. But the challenges they continue to face also come through loudly and clearly.

A failure to engage in time outs is one of the pain points, as are time pressures, communication and, most disconcertingly, an observed willingness on the part of staff and physicians to at least occasionally take shortcuts that could affect safety. Here's some of what respondents had to say.

When it comes to time outs, only 73% of our nearly 400 respondents say they can always count on full engagement from OR staff. A common theme pops up again and again. "It's difficult to engage the surgeons," says a director of surgical services from Oklahoma. "I sometimes feel that the surgeon is not paying attention," adds a clinical director from a Texas surgery center. "We complete a full time out," says a suburban New York administrator, "but at times we feel surgeons are not paying 100% attention."

Surgeons undoubtedly would like proof that time outs do more than just waste their valuable time. But to convince them, you may have to rely on a different tact.

Elizabeth Hall-Findlay, MD, FRCSC, a plastic surgeon and the medical director of Banff Plastic Surgery in Alberta, Canada, says insisting on a fully engaged time out comes down to common sense. "I just do not understand why surgeons resist," she says. "I was criticized [by other physicians] at a meeting once for not limiting the time out, but when we do them at our facility, we actually cover more than the patient, site and side."

Dr. Hall-Findlay says she also asks about cautery settings and implanted cardiac devices, and she asks her nurses to go over any and all medication on the back table — and whether there might be issues with look-alike, sound-alike drugs. "My staff know that I pay attention," she adds. "That makes them pay attention. And they're not allowed to do anything else while we do the time out. You can do 2 things at once but you cannot think about 2 things at once."

Not saying never
Nearly half (46%) of respondents say their facilities have had so-called never events: An incision on the wrong knee. A burn from an under-body cautery pad. 100% oxygen given during an ENT case. A laser event with the wrong eye. An airway fire. Strabismus surgery performed on the wrong eye. A patient burn from an electrocautery wand left on the patient's abdomen. Right side, wrong finger. A patient burned by a Bovie. Retained surgical items. The list goes on and on.

Could better communication have prevented any of them? Experts say that in addition to using time outs and checklists, staff members must repeatedly be encouraged to speak up when they have concerns.

But it's a struggle to make that happen, say respondents. Fewer than half (48.2%) say staff members always feel comfortable voicing concerns, and only about one-third (35.6%) say physicians always encourage OR staff to speak up if they think something appears to be amiss.

"We're looking into this right now, trying to tell our nurses this is not a suggestion, but that patient safety depends upon it, and they are obligated to be a patient advocate," says Greg Rawley, RN, BS, CNOR, director of nursing at the Algonquin Road Surgery Center in Lake in the Hills, Ill. "But we do have a few surgeons who are difficult to approach."

It takes a lot of effort and management support to make it happen, says Barbara Murdock, RN, nurse manager at Overlake Hospital in Bellevue, Wash. But, she says, the effort is paying off.

In potentially uncomfortable situations, it's important for staff to know that management has their backs, agrees Michelle Lynn, BSN, RN, ASC director of the Springfield (Ill.) Clinic. "Some surgeons are intimidating," says Ms. Lynn. "But the staff are always encouraged to speak up and informed that they will be supported 100% for questioning anything."

Nicolette Williams, RN, CNOR, OR director at the Lakeland (Fla.) Surgical and Diagnostic Center, says she counts on RN circulators to be "assertive and address those concerns," if physicians aren't engaging with the staff the way they should be.

Time and attitude
It may be a little shocking that only about one-fourth (23.4%) of respondents say they never see physicians or staff take shortcuts that could endanger patients. But the reasons for taking those shortcuts probably won't surprise. The biggest culprits appear to be time pressures and cavalier attitudes.

"A combination of short staffing and a staff that's under pressure to speed up the daily schedule creates risks to both patients and staff," says a Massachusetts surgical technician. "I can't always be present in the OR during time outs because I'm doing 2 jobs at the same time. I often don't get there until the procedure is underway."

"The administration is more interested in getting more done than getting it done safely," says a Charleston, S.C., nurse. "We're always rushed," adds a CRNA. "It's like herding cattle back home."

If it isn't time pressure, it may be overconfidence. "Unless surgeons have experienced a sentinel event, they don't think it will ever happen to them," says a clinical supervisor from Seattle, Wash.

Patient safety is uppermost on the minds of most, however, and more than 70% of respondents say they're always on the lookout for ways to improve it. Many say they encourage and have implemented staff suggestions.

"I'm always amazed when someone suggests something that makes sense and improves us," says Jeffrey Blank, DPM, of the Dundee Foot Center in Wheeling, Ill. "The safety checklist on my office-based operating room wall was actually developed by a new employee who brought it with her from her previous job. I thought my checklist was really good, but hers was better."

At the Lakeland Surgical and Diagnostic Center, a staff member suggested a better way to prevent surgical fires. "Whenever we do head and neck procedures under a local/MAC, we keep the entire face open so there's no tenting of drapes and no accumulation of oxygen," says Ms. Williams.

Mid-afternoon huddles to plan ahead for the next day, fire-safety reminder cards in high-fire-risk cases and special lab specimen time outs are just a few of the other ideas that facility managers say they've implemented after suggestions from staff members.

Keep at it
Patient safety requires a deep commitment, acknowledges Tallahassee, Fla.-based anesthesiologist David Shapiro, MD, CASC, former president of the Ambulatory Surgery Center Association. Time outs, for example, should be mandatory, but they shouldn't be rote. "We have worked, over time, to make it meaningful and specific to the clinical needs of the patient," he says.

And if physicians aren't encouraging all team members to speak up when they have concerns, it's important to keep working on them. "This is something we frequently discuss at medical staff meetings as part of our safety culture," says Dr. Shapiro.

You may not convert everybody, but common sense and time are on your side. Or, as another facility manager puts it: "Our goal is to provide safe, appropriate patient care. We follow safety initiatives and procedures, our nursing staff are engaged and follow procedures, and most of our physicians are engaged and participate in our safety initiatives."

There's only one problem: "One older surgeon. We haven't been successful in changing his behavior, nor have we been successful in triggering his retirement."

It's true that a few may see time outs, checklists and encouraging staff involvement in decision-making as new and unnecessary initiatives, but times are changing and the days of the dinosaur are numbered. OSM