National Time Out Day occurs annually, and this year takes place on June 14. It’s designed to draw attention to everyone on a perioperative team to take a collective pause (a “Time Out”) prior to each surgical procedure to ensure each individual is on the same page for improved patient safety.
“Time Out provides the very last safety check before incision for the team to communicate and catch any information that has been dropped or noted incorrectly. Just one error at any time in the perioperative process can and does cascade to patient harm,” said Joint Commission Chief Patient Safety Officer and Medical Director Haytham Kaafarani, MD, MPH, FACS.
According to the Joint Commission’s Sentinel Event Data 2022 Annual Review, common errors that may occur during a surgical procedure include:
- Surgery performed at the wrong site or on the wrong patient or the wrong or unintended procedure performed on a patient. The data behind the root causes of the wrong surgery include a lack of full team attention during the “Time Out,” inaccurate and non-visible site marking, and the lack of instilling a “speak up” culture, especially among new team members.
- Unintended retention of a foreign object in a patient after an invasive procedure. Sponges (44%) were the leading object type retained in a body. The leading cause behind this error include non-compliance of policies; a lack of shared understanding or mental model; and no or inadequate team communication before, during, or after a shared team task.
To address and mitigate these risks, the Joint Commission recommends the following:
- Empowering one team member to enforce full team attention
- Refining site marking for greater accuracy and visibility
- Instilling a culture where everyone feels comfortable to speak up and voice concerns
“Think for every case: This is the case when a wrong surgery will occur, so what safety steps can I take to prevent it? Keep this mentality for every procedure and treat each case with each step done perfectly,” said Kaafarani.
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