By Madelyn Jo May, RN, CNS, DNP
For more than 25 years, articles about patient safety have referenced the 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System. This report’s main conclusion was that most medical errors were not the result of individual recklessness. Instead, faulty systems, conditions, and/or processes lead people to make, or fail to prevent, mistakes.
Since that report, health care has grown in complexity and sophistication. Pharmaceuticals, robotics, electronic documentation, and AI are just a few areas that have advanced the range of viable treatment options.
So why is this report – a quarter century old – still used as the benchmark?
Despite the evolution of care, our adverse event rate has remained largely unchanged. A recent study of adverse events associated with surgical care¹ identified adverse events in 38% of perioperative cases with 49.3% related to surgical procedures. For surgeons, nurses, and techs, this percentage should be sobering. Even for errors related to “faulty systems, conditions, and/or processes,” improvement is the responsibility of individuals and teams striving to do better for their patients.
The time-out: Consistency vs. complacency
Many organizations focus on the surgical time-out as a single perioperative event – a brief, deliberate, and structured pause taken by the surgical team immediately before an incision. It can become so rote as to lose its focus as a critical feature of patient safety.
Complacency is a very real threat when we strive for process consistency. Over time, routine procedures become mechanical, and individuals fail to recognize the importance of each step in a process. Surgical teams are not immune to these pitfalls of familiarity. Well-worn practices can lead to skipping steps, rushing through the process, or treating a time-out as a quick check rather than a critical safety measure. Regular training, active team engagement, and variations in approach will break through mindless repetition and reinvigorate your staff.
Train to Reframe
Perioperative care encompasses three phases: preoperative, intraoperative, and postoperative. Similarly, the time-out process can be divided into distinct moments during surgical care: before anesthesia, before incision, and before the patient leaves the OR. In fact, the World Health Organization’s Surgical Safety Checklist², divides 19 items among those phases.
By reframing the time-out as a series of opportunities for the surgical team to stop and ensure that corresponding aspects of safe surgical care have been addressed, each pause can increase awareness, mitigate risk, and combat complacency.
You can use a PDSA quality framework to execute your training.
Plan – Step back to evaluate your time-out process. Review each element of your checklist. Be sure you understand why it is there and when it is most important. Then add time-out review as a frequent agenda item for education sessions
Do – Implement the training and vary your approach to keep the content fresh. Here are some suggestions:
1. Emphasize the what and the why. Review the items on your checklist and engage discussion about potential patient safety risks when an element is omitted. Review roles and responsibilities during a time-out to ensure that the whole team has a stake in the process.
2. Emphasize the what and the when. Set the idea that a distinct time-out will begin each perioperative phase. Recreate the journey of a patient undergoing a standard procedure and ask staff to identify the appropriate places to pause and check in. Suggest errors that could occur and celebrate “great catches” when the team can tie potential mistakes to time-out items.
Or mix up your checklist items and have the team reorder it based on the patient journey.
3. Emphasize the who and the how. Conduct a mock time-out and assign someone (preferably a surgeon or other leader) to make deliberate errors. This should help train team members to speak up. Normalize looking out for each other. In a culture of safety, every voice is valued.
Or switch roles for the scenario so that individuals see the process from another point of view and remain attentive.
Study – Conduct audits of real time-outs and seek feedback. You can assign varying team members to review how time-outs are conducted in their cases. Fresh eyes on the process can identify opportunities for improvement.
Act – Share results. When discrepancies in the process are shared, ownership of solutions is amplified. If it feels important to the group, engagement increases, and behavior changes. The goal is to keep your time-out process dynamic and purposeful.
The implementation of checklists and time-outs is widely associated with improved patient safety. It is not enough to implement the surgical timeout process, but to also ensure its consistent and effective execution. Finding ways to re-engage surgical team members in a purposeful surgical timeout is critical to preventing adverse events and improving patient outcomes.
– Madelyn Jo May is a full-time RN surveyor for ACHC’s Hospital Accreditation Programs. She has 33 years of experience in acute care, having served as director of quality, safety & regulatory compliance and as CNO. Her passion for patient safety drives her to advocate for better practices, ensuring every patient receives the highest standard of care.
