A Former Navy Pilot Explains the Theory Behind the Time Out Checklist

by KC O’Connor, President, Universal Safety Solution

 

I was standing alongside one of the observing nurses in the OR and witnessed the flawless execution of our newly created Time Out Check List performed before the start of a surgical procedure. This nurse had worked on the beta team helping us develop a new time out checklist for her hospital.

My company, Universal Safety Solution, LLC, was hired to facilitate the development and implementation of this improved Time Out Check List, a procedure I am quite familiar with as a retired naval pilot and a captain for a major commercial airline. Pilots perform similar checks as part of standard takeoff preparation.

This checklist not only incorporated the time out protocol of right patient – right procedure – right side, but I am proud to say, it also included significant human factor elements. These elements addressed the elimination of distractions, introductions for all those in the OR, and each team member presented their applicable portion of the checklist to the team.

The checklist I use on every flight does not tell me how to fly the aircraft, but rather ensures the critical items have been verified. The idea is the same in the OR. The checklist finished with the surgeon discussing critical items such as the plan for the operation, significant periods during the surgery and ended the checklist with the statement, “If anyone has any concerns during this procedure, feel free to speak up.” In my many years in positions of leadership in the military and aviation, I have found that this simple statement is extremely powerful because it tells the other members of the team that they are valued and that their input is welcomed.

While this attitude of inclusion is the rule instead of the exception in the airline industry today, this has not always been the case. In the early years of aviation, the captain was viewed as king, and his decisions were rarely questioned. Sound familiar?

That attitude changed in 1977, when two fully loaded 747s collided on the runway in Tenerife, a small island in the Canaries, killing 583 people. A collaborative study that was subsequently launched by NASA and the University of Texas revealed that most airline accidents were a result of negative human factor behavior, rather than mechanical failure. Accidents often included problems such as weak communication, a lack of team building, and poor workload management, the study showed.

Now, more than 40 years after the Tenerife collision, aviation has significantly improved its safety record and, more importantly, its attitude towards human factor behavior training. This transformation has been the direct result of not only improved technology but also continuous training in Crew Resources Management (CRM), Threat and Error Management (TEM), and a vibrant non-punitive error reporting system that educates employees as to the threats that can lead to possible errors.

The benefits of human factor behavior training were revealed to the medical community in a JAMA study dated October 20, 2010. The study concluded that mortality rate decreased as a result of “using a multifaceted intervention of medical team training, involving briefings, checklists, and communication coaching…was associated with a reduction in mortality.” Those were exactly our goals when we created the Time Out Check List at Universal Safety Solution.

Once the Time Out Check List was successfully completed, the surgeon was ready to operate. He asked the circulating nurse to turn the music back on, and then he asked the scrub nurse for the scalpel. As Mick Jaeger rocked the OR, the observing nurse leaned toward me and said she thought the music was too loud. I looked at her and reminded her of what the surgeon told all of us just moments before: “If anyone has any concerns, feel free to speak up.” She waited a second to muster her courage and then asked the surgeon if it would be o.k. to turn the music volume down so she could hear what was being said. The doctor quickly responded positively about her request and asked the circulating nurse to lower the volume.

While our Time Out Check List was designed to reinforce the protocol confirming right patient right procedure right site, it was also intended to create a team dynamic and empower all members of the OR team to communicate freely. In reality, it was a surprisingly ineffective human factor tool as revealed by the observing nurse’s inability to speak up initially about the music. This was not due to the checklist design or the demeanor of the surgeon, but rather a manifestation of the organization’s existing culture.

Creating a culture in which the staff is not afraid to speak up before problems occur is a vital part” of an effective team approach to reducing errors. Linda Groah, the executive director and CEO of the Association of perioperative Registered Nurses (AORN), explained it this way: “This (approach) has to come from the top down – there has to be an upper management philosophy of support for staff members who speak up.”

In order to create this enhanced culture of safety, organizations have to be willing to invest resources of time, staff, energy and money to offer human factor training in leadership, work load management, communication, and threat and error management; all of which work hand-inhand with valuable tools like the time out checklist.

The nurse who raised her concern about the volume of the music in the OR had little or no formal human factor training. She was not familiar with concepts such as TeamSTEPPS’ “CUS” strategy or aviation’s Crew Resource Management model of “Assertiveness with Respect” to deal with possible confrontational situations. In a study entitled “The Silent Treatment,” and carried out by AORN, VitalSmarts and the American Association of Critical Care Nurses (AACN), poor communication was revealed to be the culprit behind the majority of OR mistakes, highlighting this critical need for human factor behavior training.

While time out checklists are valuable tools to assist with improving patient safety, some estimates currently put the national incidence rate, which includes wrong patient wrong procedure wrong side surgeries, as high as 40 per week, according to the Joint Commission Center for Transforming Healthcare. The Minneapolis Star Tribune has recently reported that in the nine years during which the Minnesota Department of Health has tracked hospital errors, the error rate has not improved. These reports come more than 10 years after the Institute of Medicine issued their report in 1999, “To Err Is Human…” which cited that as many as 98,000 people die each year needlessly because of preventable medical error.

These staggering statistics demonstrate that medicine is still harming too many patients. It also reveals the urgent need for healthcare to combine an enhanced culture of safety, which supports employees at all levels of an organization with better human factor training. With this approach, a team member in the OR will be empowered to not only respectfully tell another team member that the music is too loud, but the eye they are going to operate on is the wrong one!