FEAR FACTOR Scripted messages can help nurses alert surgeons to potential trouble.

If we're all taking a time out before every surgery, then why do wrong-site anesthetic blocks and wrong-site surgery persist? Perhaps we can improve how we perform our pre-op pauses.

1Not a glossed-over routine. The time out isn't a checkbox exercise that a nurse can do alone in the corner. Staff members, surgeons and anesthesia providers must actively participate in the process. Surgeons should lead time outs, in my opinion, but that doesn't always happen. Sometimes the surgeon isn't even in the room when the time out occurs. Your docs must take ownership of the time out and set a positive example by demanding that all activity comes to a full stop and that every team member is focused and participating.

2Hello, my name is Team members should introduce themselves (or be prompted to speak) during the time out, because staff who talk during that last safety check are more likely to alert the surgeon if something seems amiss during surgery. The surgeon should make that point very clear by stating, "If you see something that would cause risk to the patient, I expect you to let me know."

3Beware of information overload. Don't cover too much information during the time out. Doing so might compel the surgical team to rush through a series of steps that would have been best addressed during the pre-op briefing, which is distinct and separate from the time out. Time outs should be reserved for focusing on the key safety points: ensuring the right patient is on the table; the correct operation is about to occur; and the correct site is marked, visible and confirmed. You also want to ensure SCIP measures have been carried out, pre-op antibiotics were given at the appropriate time and everyone in encouraged to speak up if patient safety is jeopardized.

4Use scripted phrases. It can be difficult for nurses and techs to alert surgeons when safety concerns arise. Surgeons are often viewed as the most powerful person in the room, and there's a strong tendency for staff to defer to their command. Simple scripted phrases that escalate in urgency can help team members speak up:

• I'm concerned or need clarity.
• I'm uncomfortable.
• There's a safety issue — stop!

When nurses tell me they're concerned during a case, I immediately stop to acknowledge those concerns. But that's not all. As you can see in the sidebar to the right, your OR team should conduct safety sessions before and after surgery as well. OSM

Hold Safety Sessions Before and After Surgery

TALK IT OUT Pre-surgical huddles and post-op debriefings are prime opportunities for OR teams to improve safety.

• Pre-op briefings. These are planned orientation sessions to forecast issues the surgical team might face throughout an entire day of surgery or, if you hold the huddle in pre-op before moving a patient to the OR, concerns about specific cases. For example, the team can discuss critical phases of upcoming cases — when nerve retractors are in place during spine surgery, for example — during which the surgeon wants every member of the team to remain in the room, quiet and focused on the task at hand.
• What worked, what needs work. Post-op debriefings aren't common in outpatient surgical facilities, even though the few minutes immediately after cases end, when the surgery is still fresh in everyone's mind, are the perfect time to review what went right and what could have gone better. Before you touch on what could have gone better, start by discussing what went well to get everyone comfortable with sharing their opinions. It's difficult for members of the team to criticize themselves, so the surgeon needs to step into a leadership role by showing some vulnerability with comments like, I should have told you about the possibility of needing that equipment. Finally, discuss what the team can do better during future cases and touch on specific issues or concerns that you need to resolve before the next case, such as replacing broken instruments. Debriefings lose their effectiveness without a system in place that will address and correct issues that surgeons and staff identify. Who's accountable for making that happen? Who will report back to the surgical team when the problem is resolved? Those elements have to be in place to ensure debriefings don't become pointless, time-wasting exercises.

— Dwight Burney, MD