By Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CPPS, CJCP, Associate Nurse Executive
The numbers of reported wrong site surgeries to The Joint Commission have increased from 68 in 2020 to 85 in 2021. When you estimate that only 2% of sentinel events are reported to The Joint Commission, this is trending in the wrong direction!
This increase is very likely correlated with the fact that hospitals are still catching up with surgeries delayed by the pandemic. Operating rooms (ORs) are increasingly staffed by travel nurses who may not be comfortable enough to speak out and confirm:
- patient identity
- correct surgery site
- the procedure to be done
In 2021, a staggering 1 in 10 surveys conducted across hospitals, critical access hospitals and ambulatory accreditation programs providing surgical services had findings around the time out process.
When we receive a report of a sentinel event, we work with organizations to identify root causes and share lessons learned with others. The most common root causes with failures in the time out process have to do with human error, leadership and communication.
Staff and Leadership Roles
Many of these findings could be resolved with better engagement by both staff and leadership. Leadership needs to create systems and safeguards to prevent harm due to human error. Leadership must create a culture of safety so staff can comfortably speak up before harm reaches a patient.
Of course, staff is responsible for following the correct processes put in place to prevent harm. One of the most impressive time outs I’ve ever witnessed was when the physician verbally told the team to stop the surgery if anyone witnessed anything amiss. The team understood that this physician wanted to know about their concerns.
A root cause of sentinel events—communication—demonstrates that breakdowns are the most common risk identified in the time out process. When all members of the operative team are not fully engaged in the time out, it’s actually easy for the team to miscommunicate. Each team member brings their own unique perspective and the safest time outs are those when each member participates.
History of National Time Out Day
The Association of periOperative Registered Nurses (AORN) responded to The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ by creating National Time Out Day to raise awareness. AORN also developed a Comprehensive Surgical Checklist to enable individual facilities to meet The Joint Commission’s Universal Protocol and the World Health Organization’s standards while still being able to customize the checklist according to the facility’s specific procedures.
This made significant inroads in the number of wrong site surgeries when it was first introduced more than 20 years ago and I am convinced we can continue to improve.
National Time Out Day on June 8 is the perfect time to recommit to fully engaging in the time out process. While we understand that the last 2+ years have been extremely chaotic and patient volumes are high, we ask you to Make Time for the Time Out. Together with AORN, we’ve compiled four tips to be more effective in a Time Out.
1. Observe time out best practices
Audit time outs to see how engaged team members are in every step of the time out as part of the Comprehensive Surgical Checklist established at your organization. Here are questions to ask during a time out audit:
- Is the person designated to lead the time out always leading the time out?
- Are all members of the team engaged for the complete duration of the time out?
- Are all other activities in the OR halted for the complete duration of the time out?
Even if you’ve participated in hundreds of time outs, there is still a real opportunity to learn from colleagues and counterparts at other organizations. During the last few weeks, I saw one organization practice a “mindfulness moment” during a time out and thought it was a great innovation! The physician asked the team to take a deep breath at the start of the time out and remember the purpose of keeping the individual patient safe. The entire team paused before beginning introductions and then delved into the time out checklist. This best practice was implemented during the pandemic and really has helped both staff and physicians center themselves.
Step 2: Review time out observations as a team
Findings from a series of time out audits should be reviewed by all members of the team in a non-punitive way so improvements can be discussed and agreed upon. From this discussion, the team should develop proposed time out improvements.
Step 3: Test time out improvements
Proposed time out changes should be tested prior to implementation to assess effectiveness and “fit” for every team member. I’ve seen this work quite effectively in older buildings, for instance, when a check of temperature, humidity or air flow is included. These are important considerations in older buildings and one example of how time outs can be customized to an organization’s specific improvement needs.
Step 4: Enlist a time out champion on every team
Whether it’s the surgeon, the RN circulator, or a different team member leading the time out, a designated person should champion every time out.
I really believe together we can get decrease wrong site surgeries and one way to do so is to actively engage in time outs. This not only benefits the patient, but staff as well. Nobody goes to work to make a mistake and we’re only just beginning to understand the impact of patient error on the clinician as the second victim. Let’s double down on this commitment to engage with our colleagues in the time out!
Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, is the Associate Nurse Executive in the Division of Accreditation and Certification Operations at The Joint Commission. Previously, Dr. DiBlasi Moorehead was a field director at The Joint Commission for the Hospital, Critical Access Hospital and Nursing Care Center Accreditation Programs. Since 2010, she has been a surveyor for the Hospital Accreditation Program. Prior to joining The Joint Commission, Dr. DiBlasi Moorehead was responsible for accreditation and regulatory compliance and related performance improvement activities for a five-hospital system in Louisville, Kentucky. She has also held leadership positions in nursing, quality and education during her more than 30 years in health care.