June 2003 Bulletin


Patient safety tip from Dr. Herndon—time out

Dr. Richard Wiklund, Medical Director of the operating rooms (OR) at The Massachusetts General Hospital (MGH), sent the following memo to the surgical staff on February 24, 2003:

"The Surgical Coordinating Committee has endorsed a new Surgical Site Verification ‘Time Out’ program to meet the needs for compliance with the laterality policy. The Executive Committee has asked OR Administration to develop this process to facilitate 100% compliance. Therefore, a new window is being added to the Nursing Perioperative Record. This window is a pop-up window that will be used to record ‘Time Out’ information. JCAHO recommends and MGH strongly encourages all OR cases to have a time out before the first procedure begins where the surgical team pauses and verifies the patient, the procedure and the site.

"The nurses will soon be recording this information in the perioperative record. An answer (yes, no or N/A) will be recorded for the nurse, anesthesiologist, and surgeon, and then the names of the anesthesiologist and surgeon who did or did not participate will be documented. Finally, the nurse can add a comment and then they sign the Time-Out with their password verifying their participation. The information will be required and the nurse will not be able to move past the window into other parts of the record until the Time Out information is recorded.

"It is the responsibility of ALL surgical staff members to initiate and perform this Time-Out."

The practice of a "time-out" or "preoperative briefing or huddle" before the start of a surgical case is slowly being added to hospitals’ OR protocol throughout the United States. This practice was recommended last year at a symposium for healthcare executives co-sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

At a recent JCAHO "Wrong-Site Surgery Summit," which AAOS co-sponsored, participants discussed a universal protocol for preventing wrong site surgery (see related article on page 00). In addition to requiring the marking of all surgical sites in cases involving laterality, multiple structures (i.e. toes, fingers) or multiple levels (spine), the "Universal Protocol for Eliminating Wrong-Site, Wrong-Procedure, Wrong-Patient Surgery" includes a "time-out" immediately before starting the procedure. The "time- out" process involves the entire surgical team who—in addition to completing a final verification of the correct site, procedure and patient — must agree on the position of the patient and, importantly, the availability of the correct implants and special equipment needed. Any differences among the team must be resolved before the case begins.

Most surgeons, when first hearing of this requirement, are resistant to the process because they believe it will be too time consuming! However, those who use the "time-out" regularly state it is very brief, often only one or two minutes.This process makes sense, not only to eliminate wrong-site, wrong-procedure, wrong-patient surgery, but ensures the entire surgical team is fully informed about the planned procedure and that proper equipment and implants are available. More importantly, such a process creates both a team approach and team accountability to the success of that procedure. Each member of the team is thus empowered to speak up about problems and concerns.

We have depended on sales representatives to bring the proper implants and special equipment to the OR. Consequently, hospital inventories are limited and OR personnel are often not familiar with the implants or equipment. Hospitals must return to the previous practice of providing OR personnel enough specialized experience to work with these complex orthopaedic materials.

I believe the preoperative "time out" will make this happen. It is one more step that will promote change in the culture of our hospitals to one that is safer for our patients.

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