By Don Sadler
This year marks the 20th anniversary of the Surgical Time Out, a groundbreaking perioperative practice that some have ranked with wearing gloves and following sterile procedures as among the most important changes in perioperative history.
To mark the anniversary, OR Today spoke with several perioperative industry veterans who were instrumental in helping the Surgical Time Out become a reality.
How It Got Started
William Duffy, RN, MJ, CNOR, FAAN, was the president of the Association of periOperative Registered Nurses (AORN) in the early 2000s when The Joint Commission published a list of “never events,” or events that should never occur in the operating room. Also referred to as sentinel events, these include wrong site, wrong patient and wrong procedure surgeries.
“The Joint Commission stated that these events should never occur, but they took a 10,000-foot view and didn’t say what organizations should do to prevent them from happening,” says Duffy. “I believe they thought it was up to the practicing professionals to figure it out, so initially everybody was creating their own process.”
But this didn’t solve the problem, says Duffy, because some surgeons marked the surgical site while others marked the site not to be operated on. “So, I thought, why don’t we (AORN membership) work to establish a standardized process for everyone to follow?”
Duffy took his idea to the AORN Board of Directors, which agreed with the concept. The first step was to create a taskforce that would develop a standardized process for the Surgical Time Out.
“The task force developed a Surgical Time Out toolkit that was reviewed and approved by the AORN board,” says Duffy. “The Joint Commission loved the idea of a standardized model and were early in the co-sponsoring effort, and we also got buy-in from our perioperative partner associations.”
A Surgical Time Out toolkit was mailed to every AORN member and hospital in the country. “We gave the toolkits away because we wanted everyone to adopt it,” says Duffy. “A few weeks after we mailed them out, we got requests for toolkits from hospitals in Canada, Europe and Asia.”
The final step was getting buy-in from the public.
“We knew this would be critical so we hired a PR firm and decided to create the National Time Out Day, which occurred on June 23, 2004,” says Duffy.
“We developed a ‘news report’ and rented time on a news satellite where our story could be downloaded by TV stations across the country,” Duffy adds. “Then we reached out to major media outlets. I did interviews on the CBS Early Show, Fox News, NPR, the Associated Press, USA Today and The Wall Street Journal. Our news report ended up being the top downloaded report that week.”
Overcoming Early Reluctance
AORN Executive Director and CEO Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, was the chief nursing officer and COO at a health care facility when the campaign for Surgical Time Out was developed by the AORN staff and board.
“There were a few surgeons who were early adopters of the concept, but it was not strongly supported back then,” says Groah. “Acceptance was directly related to how the process was introduced, implemented, monitored and reported on by a committee. However, perioperative nurses embraced the concept as part of their role and responsibility as patient advocates.”
Mary Jo Steiert, RN, BSN, CNAMB, perioperative leadership and patient safety consultant, was the AORN president in 2007-2008 and an invited participant (along with Groah) to the World Health Organization’s second Surgical Summit in Geneva, Switzerland, where the Surgical Checklist was developed and launched.
“Implementation and execution of the Surgical Time Out did take some time,” says Steiert. “Many surgeons felt it was an unnecessary step. In my personal experience, it took a wrong site surgery performed by a prominent neurosurgeon in our facility to hasten the recognition that the Surgical Time Out was a necessary step for safe patient care.”
Following this incident, the facility’s biggest naysayer, a cardiac surgeon, volunteered to produce a video for recertification.
“The statistics and stories of wrong side, wrong site, wrong procedure and wrong patient surgeries were just too overwhelming to ignore the problem,” says Steiert.
Steiert says that in her experience, there was pushback to the Surgical Time Out early on.
“But now the Surgical Time Out is a natural part of the beginning of care for surgical patients. It is now an expected standard of care, and the surgical checklist is the template for the Surgical Time Out.”
Groah concurs.
“The Surgical Time Out has slowly become a Standard of Practice in most health care institutions,” she says. “There will always be a few surgeons who do not adopt the practice as it may ‘delay’ the incision time. Or they think, ‘I have been doing surgery for 20 years and I’ve never operated on the wrong side or site.’
“In these situations, strong leadership committed to patient safety can make it clear that, ‘At our facility, we always perform Surgical Time Outs,’ ” adds Groah.
Promoting the Surgical Time Out
Beverly Kirchner, MSN, RN, CNOR, CNAMB, is a compliance officer and clinical resource director. She says that she supported the concept of the Surgical Time Out from the beginning and worked to promote it in every surgery center where she worked as a consultant, though there was pushback by some surgeons in the beginning. “This eased when some key physicians embraced the concept and research on the causes of wrong site surgery was published,” says Kirchner.
“The practice began slowly and still is not performed consistently on every case in every organization,” Kirchner adds. “This is why wrong site surgeries are still being reported. If all OR teams embraced the Surgical Time Out fully and followed the process every time, we could eliminate wrong site surgeries once and for all.”
For Kirchner, it’s not so much whether a Surgical Time Out is performed or not, but how many of the Time Outs performed are quality time outs with the surgical team engaged in the process. “I see nurses trying to hold the time out but the surgeon and other team members are not engaged,” she says.
Pat Thornton, MS, RN, CNOR Quality Consultant at Chastain Surgery Center, says that her first observation of the Surgical Time Out 20 years ago was that many surgeons and anesthesiologist would ignore it. “They continued to talk and started the surgery without performing the time out,” she says.
However, her facility educated the surgeons, anesthesiologists and perioperative staff about why the Surgical Time Out was so important. “Our leadership was also very active in AORN, which really helped,” she says.
Thornton says the major issue she observes with Surgical Time Outs today is that they’re not performed in surgery centers or for office-based surgeries like those performed in GI endoscopy facilities, surgical dermatology offices, cosmetic facilities and for interventional radiology procedures. “Many of these office staff don’t know about AORN Standards,” says Thornton.
Brenda C. Ulmer, MN, RN, CNOR, FAORN, says that while she has never been personally involved in a never event, she knows colleagues who have been. “From the time I started working in the OR, I was aware of incidences when the wrong limb was removed or some other type of surgical error occurred,” she says.
“The worst in my memory was removal of the wrong eye on a patient,” says Ulmer. “This was catastrophic for everyone involved. These types of errors are the ones that stay with you for a long time, which is why Surgical Time Outs are so important. The concept of taking a step back to make sure everything is correct is a hard practice to lobby against.”
After she had surgery last year, Ulmer says she was pleased to see a notation on the post-op record that a Surgical Time Out was performed. “And I have a nurse friend who was awake while having a local surgery performed,” she says. “When the surgical team completed the time out, she raised her head and told everyone she knew the person who started the time out, meaning Bill Duffy.”
Part of the Universal Protocol
The Joint Commission requires that all organizations using its accreditation standards perform a Surgical Time Out prior to the start of any invasive procedure. “The Surgical Time Out procedure is a key component of the Universal Protocol, a three-step process designed to reduce wrong site, wrong procedure and wrong person surgical errors,” says Elizabeth Mort, MD, MPH, Vice President and Chief Medical Officer with The Joint Commission.
According to Mort, before conducting the Surgical Time Out, the perioperative team should:
- Conduct pre-procedure verification to ensure all information is reviewed and any discrepancies are addressed.
- Mark the surgical site, which is critical.
- Conduct the Surgical Time Out just before surgery begins.
“Each of these steps provides opportunities for the team to ensure they identify the correct patient, procedure and site,” says Mort. “If the Surgical Time Out procedure is completed properly every time and in concert with all parts of the Universal Protocol, The Joint Commission believes that many wrong site procedures can be avoided.”
According to Mort, the Joint Commission supports a voluntary sentinel event reporting program. In 2023, the program received 112 reports of surgeries involving wrong site, wrong procedure, wrong patient and wrong implant. This is more than nine sentinel events per month nationwide.
“After reviewing the reported sentinel events from our accredited health care organizations, The Joint Commission identified the leading contributors to wrong surgeries as: no established time out or insufficient time out procedures, a lack of situational awareness and a lack of shared understanding by the surgical team,” says Mort.
Organizations cited a number of obstacles that led to defects in the Surgical Time Out procedure. “These include time pressures, lack of full engagement by all members of the team and lack of full understanding of the time out’s importance,” says Mort. “They also cited operational barriers, such as capacity issues and production pressures.”
In addition to the voluntary reporting program, The Joint Commission also conducts routine surveys of health care facilities and observes Surgical Time Out procedures in real time. Mort says that during this process, surveyors examine three components of the time out procedure:
- Whether the time out is conducted immediately before the procedure.
- How the time out is conducted (e.g., the engagement of the team).
- Whether the time out is documented.
“The most frequent time out defects identified by surveyors were related to how the Surgical Time Out was conducted, which highlights an area for improvement,” says Mort.
Mort believes that perioperative leaders can use the 20-year anniversary of the Surgical Time Out to collect and share stories that emphasize why the procedure is so important.
“Using stories of patients who have been harmed helps make the case for improvement,” she says.
“For example, at Massachusetts General Hospital in 2010, a surgeon published his own experience with a wrong site surgery,” says Mort. “His story helps bring home the importance of using the full Universal Protocol to ensure alignment and a clear path for a safe procedure for all patients.”
Legacy of the Surgical Time Out
All of these perioperative veterans believe that the Surgical Time Out has been one of the most important patient safety initiatives of the past two decades.
“The Surgical Time Out brought patient safety to the forefront by recognizing that human factors can interfere with safe patient care if not addressed,” says Steiert.
“The legacy of Surgical Time Out is that nurses and perioperative practitioners banded together and achieved a critical practice change,” says Ulmer.
Duffy agrees.
“I believe the Surgical Time Out effort showed the power of nurses to achieve change. Too many nurses think they do not have power or influence, and there were naysayers who said we were out of our lane,” Duffy says. “But we didn’t let that distract us – and as a result, we changed the way surgery is performed around the world.”
