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Moving the Needle to Zero Wrong-Site Surgeries


By Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, CEO/executive director, Association of perioperative Registered Nurses

This year—on June 12—National Time Out Day turns 15.

In 2004, the Association of periOperative Registered Nurses (AORN) and The Joint Commission created National Time Out Day to help surgical teams remember the vital importance of taking a Time Out together for pre-surgery safety checks such as surgical site verification to prevent wrong-site surgery.

Recognition of National Time Out Day each year in June has remained a strong way for surgical teams to come together for safe surgery.

Unfortunately, 15 years later, wrong-site surgery still ranks in the top three most frequently reported adverse patient events, despite the fact that these adverse patient events are 100% preventable.

Barriers to Eliminating Wrong Site Surgeries

It comes down to a need for greater vigilance, according to LuAnn Vis, RN, BSN, MSOD, associate director of High Reliability Initiatives within the Joint Commission’s Center for Transforming Healthcare.

She believes every perioperative team member must be equally accountable for their own preoccupation with any failure in the pre-surgical process that can lead to wrong-site surgery, whether it’s an incorrect notation in scheduling or a wrong-site anesthesia block in preop holding.

Is there a member of your perioperative team who does not understand the risks for wrong-site surgery?  If your answer is yes, Vis says, “then it is only by chance that a wrong-site surgery has not happened yet in your surgical setting.”

Risk Reduction in Wrong Site Surgery

Vis recommends five important ways the perioperative team can reduce the risks for wrong-site surgery and enhance collaboration in the process.

1. Understand where wrong-site surgery risks lurk in your perioperative setting.

Use standardized tools such as the to identify and respond to the risks in your system.

2. Make your patient part of the Time Out.

Take a patient-centered Time Out approach that makes your patient an active participant in confirming surgical site and other pre-procedure safety checks.

3. Give every team member an active role in the Time Out.

Use a template such as AORN’s to assign each surgical team member a voice in the Time Out process.

4. Track your Time Out successes and improvement areas.

Audit your Time Outs for accuracy, effectiveness and complete team participation to help identify improvements that can be shared and discussed.

5. Build a speak-up culture.

Staff members need to witness evidence of quick response by colleagues and leadership to any concerns they voice. This instills trust and confidence in the organization and a sense of responsibility to be vigilant and voice any concern.

Generate Excitement for your Time Out
Take advantage of these National Time Out Day recognition ideas and resources from AORN:

  1. Take a photo of your team commemorating Time Out and share it on Facebook or Instagram using #AORNTimeOut2019 for a chance to win a $100 gift card.
  2. Download a Time Out cake or cupcake topper to recognize National Time Out Day in a fun way outside of the OR.
  3. Display AORN’s Time Out Day poster to spark conversation about the importance of the Time Out among your perioperative colleagues.
  4. Write your local and state legislators and ask them to pass the AORN proclamation honoring Time Out as a patient safety essential. 

When it comes to ensuring safe surgery together, it takes a team of perioperative professionals who are vigilant, willing to speak up, and recognize the value of safety tools such as the Time Out to keep deadly errors from harming patients.

Linda Groah has been the CEO/executive director of AORN since March 2007. A veteran perioperative nursing executive, Linda has devoted her career to perioperative nursing practice, education and executive management.