Run More Effective Time Outs


Standardized protocols, clear communication and engaged team members lead to safer patient care.

It's always important to learn from the mistakes of others. When the Joint Commission recently reported 104 incidences involving wrong-patient, wrong-site and wrong-procedure events — with 60 of those events occurring in Pennsylvania — several nurses at Penn Medicine's Pennsylvania Hospital in Philadelphia decided it was time to reemphasize the importance of the pre-op time out. "The perioperative team's compliance rate with performing time outs was 60%, so we created a multidisciplinary team of nurses, surgeons, clinical directors and anesthesia providers to address the issue," says Margaret Vance, MSN, RN, CNOR, a clinical nurse education specialist at the hospital.

The team discussed an education plan based on audits of the hospital's time out process and focused on building a culture of safety that empowers all team members to call for a full stop to surgery if inaccuracies or concerns are identified during time outs.

"Now, our compliance rate is in the 80% to 90% range," says Ms. Vance. "We've haven't had any reported safety events within the past year."

Engaged and empowered

Each member of the surgical team must be actively involved in the time out. Giving every team member a specific role can help lessen their fear of speaking up if a potential problem is detected, and also emphasizes the importance of the process.

"Everyone needs to pay attention, feel empowered to speak up and have confidence that their voice will be heard," says Ms. Vance.

Fear of speaking up in the operating room when something seems amiss is a real issue, so creating a culture where everyone feels comfortable doing so is imperative. "We utilize a high five system, where the team member who speaks up during the time out receives an email that says, "Thanks for keeping Penn Medicine safer,'" says Ms. Vance. "Their managers also receive the message and it's seen by the rest of the staff. Seeing the messages encourages them to pat their colleagues on the back and let them know their catch was important and valuable."

The emails are also shared with surgical leadership during staff meetings. "It's another forum where we can recognize the staff member for their efforts," says Ms. Vance.

It's important to designate a specific team member to lead the time out, according to Tamala Proctor, MSN, RN, CCRN, a clinical nurse education specialist at Penn Hospital. "It should be someone who can refer to the consent form in the chart in order to ensure that what's noted on it matches the patient identifiers verbalized during the time out," says Ms. Proctor. "They can also use the form to confirm correct answers to questions members of the surgical team have about the procedure or patient."

Giving every member of the surgical team a role to fill during the time out ensures everyone in the room feels comfortable speaking up. It also ensures every team member will be active participants in the time out.

If the circulating nurse initiates the time out, they must confirm the patient's name, date of birth, medical record number, allergies and the procedure about to be performed. "The circulating nurse must also make sure the patient is positioned correctly, and that the surgical site marking is visible," says Ms. Proctor.

The anesthesia provider must also confirm the patient's name, date of birth and medical record number. They should announce the time of antibiotic administration and blood products that are needed, and alert the team to any airway concerns. Finally, the entire surgical team must verbally agree on the procedure that's about to be performed.

You shouldn't need to resort to attention-getting devices or tricks in order to get the team focused for the time out. "Whoever has been given the role to initiate it should simply say, 'We're ready to start,'" says Ms. Proctor. "The process should become enculturated, so that it becomes automatic as soon as the entire team gets to the operating table."

Still, you might have to manage push back from members of the surgical team who don't appreciate or fully understand the importance of the pre-op time out. "I was auditing a time out and one provider refused to stop was he was doing and take part," says Ms. Proctor. "He became visibly frustrated and expressed his displeasure when I told him to participate."

The time out should become enculturated so that it becomes automatic as soon as the team gets to the operating table.
— Tamala Proctor, MSN, RN, CCRN

The provider still refused to take part, even after Ms. Proctor's warning. She escalated her concerns about the provider up the chain of command and the hospital's leadership fully supported her efforts to engage the provider, and made sure he was an active participant in the time out process moving forward. The lesson here is that enforcing frontline practices sometimes requires support from the top.

Involving the patient

ALL INCLUSIVE Including the patient in their episode of care makes them feel like part of the team and more willing to speak up about their experience.  |  Cedars-Sinai Medical Center

During most time outs, patients are under anesthesia and not actively involved when the surgical team runs through the final safety checks. But the OR staff at Cedars-Sinai Medical Center in Los Angeles decided to test out the effectiveness of an awake time out, which includes the patient in the process.

"Involving the patient provides an additional verification," says Stephanie Bartkowicz, MSN, RN, CNOR, a circulating nurse at Cedars-Sinai. "Patients interact with the surgical team, and help confirm their identity and the surgical site."

Ms. Bartkowicz had heard that a few staff nurses and anesthesiologists were utilizing the awake time out on their own and thought it was a great idea. "Surgery is intimidating for patients," she explains. "They're often very anxious, so if we can alleviate any of that stress the overall outcome will be a more positive one. The awake time out allows patients to advocate for themselves and be active participants in their care, which is often not the case."

Awake time outs also help to identity potential issues the care team would have otherwise missed. "Patients might mention allergies or medications they're taking that they forgot to share during pre-op assessments," says Ms. Bartkowicz.

The process informs patients about the procedure they're about to undergo, a factor that improves their overall satisfaction. Staff at Cedars-Sinai surveyed patients who participated in the awake time out about the expereince. "One hundred percent of the patients answered each question positively," says Ms. Bartkowicz. "Patients who feel more involved during their episode of care feel like part of the team and have positive thoughts about their entire surgical experience." Regardless of how the time out is performed, its importance cannot be overstated. Dedicating a few minutes before cases begin to improving patient-centered care, reducing surgical errors such as wrong-patient, wrong-procedure and wrong-site surgery should always be a top priority of any perioperative team. OSM

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