Time out—the surgical pause that counts

AORN Journal,  Dec, 2004  by Nancy Charlton

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Patient safety is at the forefront of health care issues and on the minds of many in the general public. Thanks to the Joint Commission on Accreditation of Healthcare Organizations, effective July 1, 2004, health care workers have a tool to work with to address critical patient safety issues. The Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery has defined a number of areas in which to enhance patient safety. At The Methodist Hospital in Houston, perioperative team members initiated a process to address the "time out" portion of the protocol and translate it from paper into practice. The Universal Protocol states the purpose of the time out as, "to conduct a final verification of the correct patient, procedure, site, and, as applicable, implants." (1) The process is described as

   active communication among all
   members of the surgical/procedure
   team, consistently initiated by a
   designated member of the team, conducted
   in a "fail-safe" mode, ie, the
   procedure is not started until any
   questions or concerns are resolved. (1)

Having worked in nursing and as a patient advocate for more than 35 years, I decided to develop a way to ensure that the surgical pause would be communicated clearly among all members of the surgical team and ensure that we are performing the correct procedure on the correct site and for the correct patient. I envisioned a visual tool that would be available to all staff members for each procedure in which they participated. My search for ideas took me to the instrument-processing area. I looked at our instrument-tracking device and noticed the metal identification tag on the pan. The metal tag is sterilized repeatedly, so I thought it made sense to develop a visual aid made of the same material that could be seen from afar and would prompt surgical team members to conduct the crucial surgical time out.

With this idea, I called a reputable Houston-based prototype developer. Together, we developed a tent-like, brightly colored visual aid that reads "TIME OUT" in large letters. The device is designed to be placed by the scrub person over the first instrument to be used in the procedure, acting as a reminder that a surgical pause must occur. The procedure does not commence until the correct patient, correct procedure, and correct site are verified and communicated by all members of the surgical team.

THE EDUCATION PROCESS

The perioperative team on policy and procedure drafted a policy and procedure with input from each of the hospital's specialty areas, the OR subcommittee, and staff members. The OR executive committee then approved the policy and procedure.

Education about the device and its use involved

* placing posters in all OR suites,

* conducting inservice presentations for nursing and medical personnel,

* posting signs at all scrub sinks,

* holding discussions at staff meetings,

* monitoring the process on an ongoing basis, and

* obtaining staff member feedback regarding compliance.

The educational process also included gathering staff member feedback regarding the potential for errors. Risk factors for errors included

* multiple surgeons being involved in a procedure;

* multiple procedures performed during a single visit to the OR;

* unusual time pressures; and

* unusual patient characteristics, such as physical deformity or obesity.

Multiple surgeons and procedures increase the likelihood for confusion about correct patient, procedure, and site. Time pressures and unusual patient characteristics can result in the circulating nurse rushing through the patient identification and assessment processes, further increasing the potential for errors.

Support from medical staff members was vital to the device's success, so we (ie, the perioperative educators and managers) shared our findings with them. Currently, there is a 95% compliance rate in The Methodist Hospital's 67 ORs, and we continue to move toward our compliance rate goal of 100%.

This distinct visual aid has numerous advantages, including that it is

* nontoxic,

* compatible with all methods of sterilization,

* inexpensive,

* reusable,

* easy to read,

* adaptable to different services, and

* lightweight.

Perhaps the main advantage of the device, however, is that it encourages active communication and teamwork.

SHARING THE TOOL

I was eager to share this tool with as many nurses as possible, so I took an 8-ft by 4-ft poster to the 2004 AORN Congress in San Diego and received an enthusiastic response from attendees. I took the same poster to the OR Manager meeting in Chicago on Oct 4, 2004. Many attendees visited the poster and asked for information on how the device works and where to get it.

In creating this device, we created a step in the path to patient safety at The Methodist Hospital, and it has been greeted with enthusiasm and widely embraced. Leaders at The Methodist Hospital were supportive in helping make this idea a reality, demonstrating their commitment to patient safety. We know that we must continue to encourage use of the device among medical and nursing staff members and make patient safety our first priority.