Time-outs and their role in improving safety and quality in surgery

By Carlos A. Pellegrini, MD.  A time-out, which The Joint Commission defines as “an immediate pause by the entire surgical team to confirm the correct patient, procedure, and site,” was introduced in 2003, when The Joint Commission’s Board of Commissioners approved the original Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery for all accredited hospitals, ambulatory care centers, and office-based surgery facilities.¹

Purpose of the time-out

While initially viewed as a safety measure to prevent harm as a result of operating on the wrong patient or the wrong site or performing the wrong procedure, time-outs evolved to include quality patient care and enhanced performance of the surgical team. The original time-out took the form of checklists, to which the surgical care team refers at different phases of a surgical procedure.

At different stages of the operation, even at initiation of the incision, other elements are verified, including the plan for the procedure and team member assignments, as well as the best ways to communicate with team members during the procedure.

Another pause before the end of the procedure turns the team’s attention toward ensuring that no foreign bodies are left behind and that all aspects of the operation have been successfully concluded. A final debriefing takes place at the conclusion of the operation.

When practiced in this step-by-step manner, with true involvement of all members of the team led by the senior surgeon, checklists are extremely effective during the operation and postoperatively as they contribute to improved patient outcomes.

It is important to note that strong team member commitment is key to the successful implementation of checklists in preventing harm to patients and in improving quality. As someone who participated in the development and initial application of the World Health Organization (WHO) surgical safety checklist, I became convinced early on that there is no better time to establish the necessary “bond for the day” of my team than a well-executed initial time-out.

In the late 2000s, during my tenure as chair of the department of surgery at The University of Washington Medical Center, Seattle, the center was one of eight hospitals around the world that participated in the development of the WHO checklist.²

A time-out breaks the ice at the beginning of the day with respectful discussion of the steps of the operation with the patient and team members, including potential challenges and a plan B if one is needed. This initial time-out is an opportunity for other members of the team to share their thoughts, which seemed to set up the group for a good day every time.

During this briefing, I discussed with the resident assigned to the case his or her level of experience, and we planned what portion of the operation each of us would perform and set expectations for the rest of the procedure. We reviewed aspects of the patient medical history that may have been somewhat unrelated to the operation to be performed, yet vital to the anesthesiologist and other members of the team.

When done well, these time-outs reflected a patient-centered safety culture and developed an environment of trust in staff who were empowered to report patient safety events without fear of reprisal, while acknowledging that humans are fallible and make mistakes.³

During the time-out, the team comes together and develops a shared mental model of what the procedure will be like, increasing the chances that all members will have the situational awareness needed to prevent harm. It also establishes the leadership of the team and empowers all members to work on behalf of the patient. Administration of drugs, control of glycemia, allergies, and other factors that can affect an operation’s outcome are discussed in these briefings.

More work to be done

Despite the progress in time-out implementation, 104 sentinel events involving the wrong patient, wrong site, or wrong procedure were reported in 2016, according to data from The Joint Commission, making them the second-most reported sentinel events of the year.⁴ From 2005 to 2016, a total of 1,281 wrong patient, wrong site, or wrong procedure sentinel events have been reported to The Joint Commission, underscoring the crucial need for effective preoperative communication and planning for surgical teams.⁴*

Some errors related to misuse of time-outs/checklists as determined by The Joint Commission include the following:

• Time-outs occurring before all staff members are ready or before prep and drape occurs
• Performing time-outs without full participation of the staff
• Lack of senior leadership engagement in the time-out
• Staff feeling passive or unable to speak up
• Inconsistent organizational focus on patient safety
• Policy changes made with inadequate or inconsistent staff education
• Distractions or rushed time-outs

National Time Out Day

The Joint Commission supports the Association of periOperative Registered Nurses’ (AORN) National Time Out Day, an initiative that began in 2004 that calls for surgeons and surgical teams to hit the pause button before starting an operation and to review the importance of creating a safe environment for every patient, every time. The National Time Out Day’s Theme is “Be a SUPERHERO—take a time-out for your patients,” which is an acronym that stands for the following:

• Support a safety culture
• Use The Joint Commission’s Universal Protocol and AORN’s Surgical Checklist
• Proactively reduce risk in the OR
• Effect change in your organization
• Reduce harm to patients
• Have frank discussions about hazardous situations
• Empower others to speak up when a patient is at risk
• Respect others on the surgical team
• Openly seek opportunities for improving patient safety

National Time Out Day ties into safety culture development for surgical teams, a concept frequently addressed in this column. By opening the lines of communication between all members of the team, and strengthening and empowering those relationships, every member of the team feels comfortable speaking up before, during, or after a procedure.

For more information on time-outs or National Time Out Day, visit the AORN website.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

References

1. The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Glossary. Oakbrook Terrace, IL. 2017 update. (Manual and corresponding updates are subscription-based.)
2. Haynes AB, Weiser TG, Berry WR. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5)491-499.
3. The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. The Patient Safety Systems Chapter, Update 2. Oakbrook Terrace, IL. January 2016. Available at: www.jointcommission.org/assets/1/18/PSC_for_Web.pdf. Accessed March 30, 2017.
4. The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission. January 13, 2017. Available at: www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf. Accessed April 20, 2017.

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