A couple of years ago, on a day like any other day in the OR, a patient was rolled into the room, put to sleep, and positioned for surgery. Their leg was prepped and draped, and everyone in the room was ready to start the procedure. The circulator called for the time-out, and as the surgical team reviewed the procedure, positioning, and surgical site, a stark realization struck them all: “We’ve prepped the wrong leg.”

That realization hung heavy in the room. Everyone recognized the gravity of the situation and the seriousness of the error that had just been avoided. The circulator was nauseous from the thought of what could have happened, but the entire team breathed a collective sigh of relief as they quickly broke down the drapes and pulled new ones. The patient was re-prepped and re-draped on the proper side. And after another time-out was performed, the procedure moved on, as scheduled, on the correct side of the patient’s body.

I wasn’t the circulator in this case, but I was there the day it happened. I helped pull the new supplies and helped get the patient properly prepped for surgery. And even though I wasn’t directly involved in the error, it was unsettling to think about what almost happened. What we almost did to the patient. It was a terrifying thought.

I’ve also experienced incidences that didn’t have such a good ending. Times when the error wasn’t caught, and I’ve witnessed the terrible fall-out from a surgical error. It’s a horrible thing to think that our patients trusted us for their care, but we made a mistake. A mistake that could have been caught if everyone was paying attention.

It’s these avoidable errors that our time-outs are aimed at preventing.

And I don’t mean a “time-out” where anesthesia is still talking, the scrub is still setting up their back table, and the surgeon is asking for the music to be turned up. I’ve been there, I know that this happens. The time-out gets treated like a delay, or an inconvenience, and it isn’t given the proper attention. If the circulator is the one responsible for initiating the time-out, oftentimes they’re left yelling over the noise that is already in the room, trying to get anyone to participate, or even acknowledge that they’re speaking.

This isn’t the way a proper time-out should be performed. But how often does it happen? How often do we have to yell over the noise to get people to listen? How often do we actually get everyone’s full, undivided attention?

Too often, we don’t. Yes, every facility is different, and every OR has different ways of enforcing the time-out process. Some places do an amazing job while other operating rooms pay lip service to the time-out, but it’s essentially non-existent. Yet, in almost every OR, a time-out is properly conducted whenever an auditor is watching. Which proves, of course, that everyone knows how the time-out should be done, whether or not it happens properly on a regular basis.

So, what does a “proper” time-out look like?

According to the Joint Commission, three questions should be the basis of every time-out. (source)

• Is this the right patient?
• Is this the correct procedure?
• Is this the correct side of the body?

Every patient deserves the consideration of these three questions before we operate on them. However, these three questions are a bare minimum, there’s certainly more that can be included in our time-out process. But, before we risk causing harm, we should be taking the time to ensure our patient’s safety.

When should the time-out be conducted?

The time-out should occur immediately before starting an invasive procedure or making an incision. This means that our patient is prepped, draped, and ready for surgery. We aren’t doing the final time-out as soon as we roll into the room, or whenever we feel like it’s “a good time to get it done.”

The reason that we wait to do the time-out prior to the incision is that it’s our final stop. One last chance to double-check, to make sure that we have done everything correctly, and that we are prepared to safely, and correctly, perform our patient’s procedure. This is not the time that most surgeons want to stop and stand still. I get that. They’re ready to start the procedure, and this feels like an inconvenience. But, just like the time where the team had prepped the wrong leg for surgery, would the error have been caught if the time-out had been done earlier in the process?

That final pause, that last check, is for your patient’s safety, as well as your own. We’re human, and prone to error. But in an environment where errors can have disastrous consequences, all of us should welcome one last chance to confirm that we are doing everything correctly.

Who is involved in the time-out?

The Joint Commission states that “the time-out involves the immediate members of the procedure team: the individual performing the
procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.” It also states that “all relevant members of the team should actively communicate during the time-out.” (source)

If we’re in the room at the beginning of the procedure, we’re to be actively involved in the time-out. We stop what we’re doing, and we pay attention. We’re the surgical team, and together we’re ensuring that everything is correct.

Who leads the time-out?

Every facility should have a standardized process for their time-out, along with a designated person to initiate it. In some places, anesthesia leads the time-out, in others it’s the circulator. Some facilities practice a surgeon-led time-out. Regardless of who it is, the point is that it’s the same person designated to initiate it, everyone is aware of the process, and a standardized process is followed.

But what if people won’t pay attention?

OK, so this is the hard part. It’s very common to have circulator-led time-outs, and it’s also very common for circulators to have to yell to make their voices heard. Too often surgeons will try to multi-task during the time-out, instead of standing still. When this happens, does the circulator stop and correct the surgeon? Or do they just ignore them and get their time-out finished?

Even when working with an intimidating surgeon, the right thing for our patients is to demand everyone’s undivided attention. How we do that varies, but if you feel powerless, talk to your OR leadership. Make them aware of the issue, and insist that they support their staff. When leadership supports and empowers their staff, when they enforce a culture of safety and compliance, and when there are actually consequences for non-compliance, then the standard is set higher. The bar is raised, people are held accountable, and the time-out becomes as integrated into the surgical process as the surgical count or anything else.

Patient safety is our priority.

Patient safety should be our highest priority, not just in words, but in practice. This is more important than bottom lines, profit margins, or surgeon/staff satisfaction. We ensure patient safety every time we pause, double-check, and time-out before the incision. A proper time-out puts our priorities into practice, and ensures the safety of our patients, each and every time.

Until next time,

Melanie

Read More:

• If you missed my last post, I’ve been busy co-hosting a new podcast, First Case! You can read about it here.
• If you want to read about the opinions and frustrations of others dealing with time-out issues, you can read my Facebook post on time-outs here.