National “Time Out” Day: Preventing Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
“Time out”, a strategic pause prior to starting any procedure for review of key parts of that procedure with all participating personnel, was established to enhance communication in operating rooms and prevent errors. The National “Time Out” Day is a once a year campaign to raise awareness of errors occurring in the surgical arena. It has been created by the Association of periOperative Registered Nurses (AORN), and backed by The Joint Commission, to increase mindfulness of safe practices that lead to optimal results for patients undergoing surgery and other invasive procedures.
The “time out” is an effective tool in supporting both patient safety, and the surgical teams’ ability to speak up for safe habits in operating suites. The Joint Commission and AORN both urge health care organizations to pledge to conduct a safe and effective “time out” for every patient, every time. This annual National “Time Out” Day brings appreciation to the value of taking a time out, but it is important to acknowledge that wrong site, wrong procedure and wrong patient surgeries are even now occurring daily in the U.S. These errors are accurately referred to as never events. They are errors that should never occur and show grave underlying safety problems.
Site marking is a core component of The Joint Commission’s Universal Protocol to prevent never events. The Universal Protocol also specifies use of “time out” prior to all procedures. It was initially designed for operating room procedures, but “time out” is now required before any invasive procedure, such as bronchoscopy or colonoscopy. The “time out” is the last thread of protection prior to an adverse event occurring. All members of the surgical team must be entirely engaged.
Communication issues are consistently revealed as a prominent underlying factor leading to never errors. Accordingly, the entire team is held responsible for following the proper “time out” procedures. Team members should feel empowered to speak up if they see something that could result in a never error. Comprehensive efforts to improve surgical safety have incorporated timeout principles into surgical safety checklists.
For your cases involving surgical procedures, Krug Consulting’s legal nurse consultants can review the “time out” documentation and checklist. Where the relevant images properly labeled? Was all equipment available in the room? Where the sterilization indicators confirmed? Was the antibiotic within 1 hour before incision?
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