A Simple Tool to Improve High Reliability | Joint Commission
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A Simple Tool to Improve High Reliability


Jun 02, 2017 | 3494 Views

By Coleen A. Smith, RN, MBA, CPHQ, CPPS
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

The Joint Commission Center for Transforming Healthcare estimates that the national incidence rate for wrong patient, wrong site, and wrong procedure surgeries may be as high as 40 a week. From 2005 to 2016, a total of 1,281 wrong patient, wrong site, and wrong procedure sentinel events were reported to The Joint Commission.

National Time Out Day

In light of these continued incidents of patient harm, The Joint Commission supports the Association of periOperative Registered Nurses’ (AORN) National Time Out Day — an initiative that began in 2004 and calls for surgical teams to hit the pause button before starting an operation in order to create a safe environment for every patient, every time.  

This year’s National Time Out Day is Wednesday, June 14, and the theme is
Be a Time Out SUPER HERO for patient safety:

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

I think the superhero symbolism sums up who we are in the eyes of our patients. We need to be strong and stand up for what is right to keep our patients safe.

We know that the health care system is riddled with opportunities for error. The time out is central to achieving high reliability. It offers a brief, pre-operation case discussion about what we expect to happen during the procedure and if we are prepared. Consistently observing the time out before every surgical procedure can help prevent patient harm.

Time outs address questions such as:

  • Do we have the right equipment in the operating room?
  • Do we have the right people in the room?

Obstacles to Time Outs

Though well-intentioned, time outs aren’t always performed with the maximum efficiency.

Some errors related to time outs as determined by The Joint Commission include the following:

  • Time outs taking place without all staff members present, or before prep and drape occurs.
  • Performing time outs without full participation of the staff.
  • Lack of senior leadership engagement in the time out.
  • Staff feeling too intimidated to speak up.
  • An inconsistent organizational focus on patient safety.
  • Policy changes made with inadequate or inconsistent staff education.
  • Distractions or not enough time to conduct a proper time out.

National Time Out Day ties into the development of a safety culture for surgical teams. By opening lines of communication between all members of the team, everyone feels comfortable speaking up before, during or after a procedure to prevent these types of errors.

Both AORN and The Joint Commission have gathered resources to help promote National Time Out Day in your health care organization. More information is available here.

The time out requirements are outlined in The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ or the “Universal Protocol” as we call it. Since 2004, The Joint Commission has required the use of the Universal Protocol before every surgical procedure.

We know that a proper time out helps to reduce patient harm, so let’s all step up on National Time Out Day and be the superheroes that our patients need.

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