TABLE TALK
10 Years In, Why Time Out Still
Matters
I
n January, The Joint Commission’s Universal
Protocol for the Prevention of Wrong Site,
Wrong Procedure, and Wrong Person SurgeryTM
turned 10 years old. During the past decade, the
Universal Protocol has become widely adopted and
is nearly synonymous with patient safety. Its three
fundamental components are preprocedure verifi-
cation, site marking, and time out. Perioperative
practitioners who use the Universal Protocol to
prevent medical errors have learned that process
alone does not provide a safety net for preventing
wrong-person, wrong-site, or wrong-procedure
events in the surgical setting. According to The
Joint Commission, failures in leadership, commu-
nication, and human factors were the top three
causes of more than 900 wrong-site surgeries re-
ported from 2004 to 2013.1
http://dx.doi.org/10.1016/j.aorn.2014.04.009
Ó AORN, Inc, 2014
The importance of this patient safety issue in the
United States dates back to October 1997, when the
American Academy of Orthopaedic Surgeons issued
a call for unified efforts to end wrong-site surgery
and outlined steps to help prevent their occurrence.2
The following year, The Joint Commission released
the first of two Sentinel Event Alerts on the topic.3
The second of those alerts, published in 2001, re-
ported a rapid increase in the number of wrong-site
surgeries, from 15 in 1998 to 150 in 2001. More than
80% of those wrong-site surgeries were self-reported
(eg, surgeon, perioperative personnel); the remainder
came from other sources (eg, patient complaints,
the media).4
In 2000, the Institute of Medicine published the
report To Err Is Human: Building a Safer Health
System,5 and awareness of patient safety issues
June 2014 Vol 99 No 6
AORN Journal j 783
June 2014 Vol 99 No 6
related to medical errors increased to the national
level. AORN was an early supporter of emerging
efforts directed at the patient safety agenda. In April
2002, AORN launched the Patient Safety First pro-
gram. AORN Past President Donna S. Watson, MSN,
RN, CNOR, FNP-BC, when reflecting on the launch
of the program, described it as “an initiative that
focuses on decreasing errors in surgical settings and
creating resources to help perioperative clinicians
provide safe patient care.”6(p21) In 2004, The Joint
Commission introduced the Universal Protocol, and
AORN responded by creating a National “Time Out”
Day to support the initiative and raise awareness of
the patient safety issue. The first National Time Out
Day took place on June 23, 2004, and was created in
partnership with The Joint Commission, the Amer-
ican College of Surgeons, the American Society of
Anesthesiologists, the American Society for Health-
care Risk Management, and the American Hospital
Association.7 This year’s National Time Out Day
will be June 11, 2014. Educating perioperative
nurses about correct site and patient identification
was also a top priority for AORN at that time.
A timeline of key events and initiatives related to
AORN’s role in improving patient safety appeared
in the June 2012 “Patient Safety First” column of the
AORN Journal.7 What is striking about the timeline
is that it outlines a shift in perspective that has
been occurring regarding the Universal Protocol. A
checklist is no longer considered the sole solution to
creating a safer surgical environment. As Lucian L.
Leape, MD, suggested in a commentary about snags
in the checklist process, a checklist is one of several
tools or initiatives that support a culture of safety.
His analysis contended that operationalizing a pro-
cess is a “social problem of human behavior and
interaction.”8 I believe this framework provides the
basis for further thought regarding the Universal
Executive perioperative nurse’s perspective
Four years ago, in this “Table Talk” column, I
shared lessons learned from a wrong-site surgery
experience at Beth Israel Deaconess Medical
784 j AORN Journal
TABLE TALK
Protocol during the next decade of time out: “As
other industries have learned, safety does not depend
just on measurement, practices and rules, nor does it
depend on any specific improvement methods; it
depends on achieving a culture of trust, reporting
transparency and discipline.”9(p424)
It is fitting on this 10th anniversary of National
Time Out Day that “Table Talk” is devoted to this
topic and that one of the commentaries comes from
The Joint Commission. The contributions from our
esteemed panel will challenge the perspective of
patient safety being as simple as completing a
checklist. According to Urbach et al,10 improving
patient safety requires more than adoption of a
checklist. In an interview, the author explained that
“[patient safety] is not as easy as a checklist . . .
Training and teamwork are key.”11 Safety priorities
must encompass a new perspective of understand-
ing and teamwork to address failures in leadership,
communication, and human factors. Only in a
culture of safety can perioperative practitioners
create a culture change and improve processes of
care.12 Each of our contributors was invited to
respond to the following statement:
From your perspective, comment on why
wrong-patient, wrong-procedure, and wrong-
site surgery continues to be a patient safety issue
and why you believe efforts toward a focus of
every patient, every procedure, every time still
matters as we commemorate the 10th anniver-
sary of National Time Out Day.
CHARLOTTE L. GUGLIELMI
MA, BSN, RN, CNOR
PAST PRESIDENT, AORN
PERIOPERATIVE NURSE SPECIALIST
BETH ISRAEL DEACONESS MEDICAL CENTER
BOSTON, MA
Center, Boston, Massachusetts, and the approach
that team members took to tackle the behavioral
and practice changes needed to establish a new
TABLE TALK
standard of safety culture and a new time-out pro-
cess.13 Certainly, the initial focus of our response
was to embed a time-out process that would be
adopted by all team members. Perioperative leaders
recognized the need for immediate process rede-
sign. Of equal importance, though, was the value of
stakeholder participation and support, which would
require focusing more time and attention on creating
new behaviors and implementing a new approach.
According to Leape et al,9 a culture that supports
a patient-safe environment is one in which
n there is a commitment to learning,
n practitioners respect those who participate in
patient care,
n the patient is always the focus, and
n patients and their family members are fully
engaged in their care.
The process redesign at Beth Israel Deaconess
Medical Center was successful because leaders
responded by first establishing a framework of
respect and trust for the perioperative team.
In another article, Dr Leape outlined three steps
to consider when introducing processes, such as
checklists, the first two of which mirror the actions
that we took in our redesign process: first, per-
forming the process, and not simply completing the
checklist, is critical; second, consideration of hu-
man factors is vitally important.8 Team members
responsible for recrafting the time-out process were
surgeons, anesthesia professionals, nurses, and
surgical technologists whose daily practice is at the
point of care in our ORs. This group determined
that a scripted time-out model was needed to im-
prove communication and that factors other than
whether the time out was completed according to
policy (eg, behaviors) would have to be addressed
to achieve culture change.
The issue we explore now is why continuing
to focus our efforts on time out still matters.
AORN documented some jarring US statistics from
the Joint Commission Center for Transforming
Healthcare:
www.aornjournal.org
n Each year, 1,300 to 2,700 wrong-site surgeries
occur.
n On average, 40 to 60 wrong-site surgeries occur
weekly.
n Inadequate planning is the attributable cause
of 85% of analyzed wrong-site surgeries.
n A defect in the time-out process is the attrib-
utable cause of 72% of analyzed wrong-site
surgeries.14
Even after a decade of hardwired time-out prac-
tices, wrong-site surgeries related to inadequacies
and deficiencies in the time-out process are not a
surprise to any of us working in the perioperative
environment. The cause of inadequate or defective
time outs can range from inconsistent practice to a
lack of participation. Clearly, there is a need for
interventions to address wrong-site surgeries, but
we must examine why defects continue to occur.
In an article about the normalization of deviance,
Banja15 contended that it is imperative for health
care organizations to be proactive in recognizing
unsafe practice deviations before they become
standard and undermine the efforts for patient
safety and the morale of health care providers.
According to Banja, the key to being proactive is to
stay out in front of what is happening every day.
There are several ways for perioperative teams to
achieve this level of readiness and vigilance. For
example, auditing or mystery shopping the time-out
process in real time can be helpful in assessing the
effectiveness of a facility’s time-out process. For
mystery shopping to adequately address the human
factors in the time-out process, observational ele-
ments should answer these questions:
n Was there active and full participation in the
time out by members of the team?
n Was the time out performed in real time?
n Were all distractions (eg, music) minimized
during the process (eg, muted, turned off)?
Another way organizations can be proactive is
for team members to use interventions that help
identify issues before they become medical errors.
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Interventions available to perioperative leaders in-
clude communicating and establishing a culture
of empowerment, in which all team members can
speak up when there is a lack of participation or the
hard stop of the time out has not happened. In-
terventions available to perioperative team mem-
bers include speaking up and holding one another
accountable.
Proactive efforts affirm the value of all members
of the perioperative team and encourage their full
participation in the time out. For example, at our
facility, we conduct a weekly huddle that is atten-
ded by senior leaders, including the associate chief
nurse of perioperative services; the associate chief
nurse of East campus/women’s health; the chair
and vice chairs of surgery, anesthesia, and obstet-
rics and gynecology; the chief of orthopedic
surgery; the director of patient safety; the chief
nursing officer; and the perioperative clinical nurse
specialist. This group is responsible for the stra-
tegic planning and development of a safety culture
in the perioperative surgery department, one that
facilitates creation of an environment in which
The Joint Commission perspective
Despite years of focus on the elimination of
wrong-site surgerydincluding implementation of
protocols, checklists, and safety campaignsdthe
problem persists. Patients continue to experience
harm from unsafe processes in the surgical arena.
Some estimates put the number of wrong-site
surgeries at 1,300 to 2,700 annually in the United
States.16 Surgeons have a 20% to 25% chance of
performing a wrong-site surgery at least once in
their career,17 and a 300-bed hospital can antici-
pate, on average, one wrong-site surgery annu-
ally.18 The statistics are a clear indicator of why
the problem must be approached in a different
manner.
Part of the reason wrong-site surgery persists is
that it is difficult to monitor, given the infrequent
occurrence at any one organization. Research has
shown that typically there is not one root cause of
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TABLE TALK
team members provide optimal safe patient care,
support teamwork, remove barriers to achieving
safety goals, and assist in spreading learning
throughout the medical center. Recurring agenda
items include reviewing safety concerns from the
previous week, planning the quarterly combined
safety grand rounds, and responding to serious
reportable events.
Why is it important to continue to focus our
efforts on the time out? Success with patient safety
can be achieved only through the continual vigi-
lance of perioperative leaders and team members
alike. Together, we can establish a culture of em-
powerment that supports the time-out process,
makes safety a priority of every person, and allows
us to reach the goal of doing no harm.
ELENA G. CANACARI
RN, CNOR
ASSOCIATE CHIEF NURSE, PERIOPERATIVE
SERVICES
BETH ISRAEL DEACONESS MEDICAL CENTER
BOSTON, MA
failure. Instead, such events are frequently the
result of a cascade of small errors that are able to
penetrate organizational defenses.19
For many years, The Joint Commission has
promoted the use of the Universal Protocol for
Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery. Members of The Joint
Commission now realize that the Universal Pro-
tocol is not enough to prevent a wrong-site surgery
from occurring. Work by the Joint Commission
Center for Transforming Healthcare has provided a
greater understanding of the causes leading to a
wrong-site surgery. This work includes the Center’s
project with eight facilities: five hospitals and three
ambulatory surgery centers. Personnel from those
facilities uncovered a series of defects that con-
tributed to the risk of wrong-site surgery, which
spanned the perioperative surgical process (ie, from
TABLE TALK
the time a procedure is scheduled to the time of
incision). For example, a time out without full
participation by all critical surgical team members
in the OR was identified as a contributing factor
that increased the risk of a wrong-site surgery.20
Personnel from the facilities were able to identify
causes of errors and take steps to correct and im-
prove weaknesses in their systems. Those targeted
efforts led to a reduction in the risk of errors
across the entire surgical process, including a
46% reduction in surgical booking defects, a 63%
reduction in preoperative or holding area defects,
and a 51% reduction in OR defects.20
Data from this project demonstrated that a tar-
geted approach that is tailored to an organization’s
unique contributing factors is critical to the preven-
tion of wrong-site surgery. These results led to the
development of the Center’s Targeted Solutions
ToolÒ (TSTÒ) for Wrong Site Surgery (http://www
.centerfortransforminghealthcare.org/tst.aspx), an
online application available to organizations that are
accredited by The Joint Commission. Health care
organizations can use this online application to
improve surgical processes and decrease the risk
of wrong-site surgery. How the TST works is as
follows:
n The online tool incorporates education, project
management, and data analytics into a step-
by-step process to measure performance. Data
and information that users enter are secure and
not available to accreditation surveyors.
n The TST quickly transforms data into user-
friendly charts that provide important infor-
mation, such as the rate of defective surgical
procedures per day and the percentage of those
Surgeon’s perspective
When I was a resident, one of my mantras was
“I don’t trust anybody, including myself.” Not only
did I check up on the work of others, I frequently
double-checked myself as well. It was a not-
infrequent occurrence that I discovered errors and
omissions made by others but also by me. A sense of
www.aornjournal.org
procedures that contain more than one defect.
The TST also can generate a breakdown of re-
sults by category (eg, specialty, surgeon).
n The TST allows teams to target only those areas
that need improvement. Custom data analysis
can lead a surgical team to achieving solutions
that are targeted to the top three or four key risk
areas.
In addition, TST users receive detailed imple-
mentation guides and checklists. An organization
can begin to see improvements in eight weeks, and
most organizations complete a TST project in 14
to 16 weeks. (For more information, call 630-792-
5800 or send an e-mail to tst_support@tcthc.org.)
The value of the TST is that it provides a
customized approach to measuring risk specific to
wrong-site surgery and addressing small errors that
have the potential to lead to adverse medical out-
comes. This level of focus and customization has
refined the Center’s understanding of how to help
health care organizations address the issue of
wrong-site surgery. The Center’s position re-
mains that a wrong-site surgery should never
occur, and we will continue to support efforts
to remove barriers to excellent performance.
ERIN S. DUPREE
MD
VICE PRESIDENT AND CHIEF MEDICAL OFFICER
JOINT COMMISSION CENTER FOR
TRANSFORMING HEALTHCARE
OAKBROOK TERRACE, IL
Disclaimer: The Joint Commission perspective is
published here by AORN under a licensing agree-
ment with The Joint Commission.
personal responsibility for the patients in my care
and the realization that small errors can snowball
into morbid consequences are what drove my be-
havior back then. Now that my name is blazoned
across a chart as the responsible attending physician,
this sense of responsibility is even more heightened.
AORN Journal j 787
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As busy practitioners who are frequently fighting
our environment all day long to get patients on
the OR bed in a timely fashion, we want to move
fast and work efficiently. When time outs were
first required, they felt like one more barrier thrown
in the way of getting through a day in the OR.
Whenever any data, such as from Aveling et al,21
demonstrated that a safety checklist component did
not prevent an erroneous surgery, it was so easy to
say, “See? It doesn’t even work.”
However, research has shown that one of the
most common sources of medical mistakes related
to wrong-site surgery is a lack of focused attention
to the job at hand.22 With busy schedules and the
constant flow of external stimuli (eg, pagers, cell
phones, e-mail, text messages), it is easy for prac-
titioners to be distracted by the next task, thereby
giving only cursory attention to the task at hand.
I have come to embrace the time out as one final
check of myself and every other team member
who is involved in the patient’s care before making
an irrevocable error with a knife. As time out has
become an important part of my routine, I have
noticed more “misses” that the time out identified;
for example, the time out allowed team members to
recognize that wrong antibiotics were ordered or
Anesthesiologist’s perspective
Let’s stipulate that every member of the perioper-
ative team understands the importance of con-
firming patient identity, planned procedure, and
laterality. Let’s further agree that establishing those
elements is seldom intellectually complex. How is
it, then, that errors continue to occur? Albeit, errors
related to wrong-site surgery occur rarely in the
30 or 40 million surgical procedures performed
annually in the United States. We as practitioners,
however, see well-intentioned, well-trained health
care professionals undertake the straightforward
task of completing the safety checklist, which is
far less complex than nearly any other element
of care they provide, with a stubbornly persistent
failure rate. I suspect that a clue to answering why
788 j AORN Journal
TABLE TALK
administered, the patient was in the wrong position,
heparin had not been administered, the required
equipment was not in the room, or an allergy had
not been recognized. Although the “captain of the
ship” concept may have fallen out of vogue, inev-
itably someone has to be the responsible leader
of the surgical team; therefore, any complication
that results from a miss during a procedure that I
perform is ultimately attributed to me.
Rather than give in to the pressure to move fast, I
embrace the opportunity that the pause of the time out
provides. It is a brief 30 to 60 seconds during which I
allow myself to clear my mind of other issues and
make myself focus on the moment. Before I plug in
my mobile device and start the background music,
before I head out to the scrub sink, before the field
is prepped, I stand with the patient asleep below
me. I pause to breathe in, breathe out, and then
announce to the room, “Let’s do the time out.”
I don’t trust anybody, including myself.
SHARON BACHMAN
MD, FACS
GENERAL SURGEON, SURGICAL SERVICES
INOVA MEDICAL GROUP
FALLS CHURCH, VA
wrong-site surgeries occur may be found in exam-
ining the time at which critical checklist steps must
occur, namely, in the period between procedures in
the OR holding or preoperative area and in the first
minutes after entering the OR.23
The expression of the pressing need to control
health care costs in the OR is often found in the
drive to increase productivity and make efficient
use of personnel and high-cost equipment. De-
creasing turnover times puts the most pressure on
the assessment of the patient in the preoperative
area. The assessment period represents the best
available opportunity for all perioperative team
members to confirm identity and procedure and to
develop a common understanding of patient and
TABLE TALK
procedure details; at the same time, however, team
members are expected to maximize speed of pro-
cess during this phase of care. Increased emphasis
on the accountability of personnel for their effi-
ciency statistics creates a personal interest that is
potentially in conflict with performing a thorough
preoperative assessment. These competing objec-
tives invite the following question: are there new
approaches to confirming identity and procedure
that are more reliable and faster than trying to
perform the same assessment in less time?
Let’s begin by considering the answer to this
question with a scenario. A patient is taken from
the holding area to the OR or procedure room. In
the OR, anesthesia is induced; the patient is posi-
tioned, prepped, and draped; and a time out occurs.
A team of at least four surgical team members as-
sembles in the room. Music is playing, and multiple
simultaneous conversations are occurring. The
discussion might be social or professional and may
or may not pertain to the patient. Last-minute re-
quests for equipment and supplies are announced.
Suction devices, patient warmers, overhead paging,
and physiological monitor alarms also contribute to
a high level of ambient noise, as do the chimes and
rings of various personal communication devices.
Meanwhile, the anesthesia professional is engaged in
arguably the most complex aspect of the care he or
she provides. Right in the midst of this mayhem is
the time out, the last, best chance to avoid a tragic
and completely preventable error in patient care.
In October 2009, cockpit crew members aboard
Northwest Flight 188 were scheduling vacations
on the company’s web site and missed their desti-
nation by 150 miles. Following this incident, the
Federal Aviation Administration responded24 by
emphasizing its 1981 rule prohibiting nonessential
cockpit conversation and distraction during takeoff
Surgical technologist’s perspective
As we celebrate the 10th anniversary of National
Time Out Day, patient safety continues to be a
primary focus of health care providers who strive to
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and landingdthe so-called sterile cockpit rule. Just
as health care has adopted aviation’s approach to
checklists, there is now interest in applying the
sterile cockpit principle to critical periods in patient
care.25-28
The relevance of the sterile cockpit rule to the
preceding question and scenario is obvious and
suggests that prohibiting nonessential conversation
in the OR could enhance checklist performance
and improve team communication generally. The
challenge of implementing the sterile cockpit rule
in the surgical setting would be partitioning several
hours of OR time into sterile and nonsterile periods
to meet the needs of all perioperative team mem-
bers, each of whom may have their own distinct
and nonoverlapping critical periods. It may be that
the surgical application of the sterile cockpit rule
would require all procedure time in the OR to be
considered “sterile,” but recognizing that we are
social animals argues for a more limited approach.
Meanwhile, as we encourage all team members
to speak up if a concern about patient safety arises,
this empowerment should be extended to creating
the expectation that nurses, surgical technologists,
and physicians alike can invoke a sterile (ie, silent)
period when their tasks demand it and when dis-
tractions are degrading their performance. I have
often wished that I had a starter’s whistle to get
everyone’s attention when the surgical environment
becomes so chaotic I can’t hear anyone and no one
can hear me. Let’s hope it doesn’t come to that!
ALEXANDER A. HANNENBERG
MD
PAST PRESIDENT, AMERICAN SOCIETY OF
ANESTHESIOLOGISTS
ASSOCIATE CHAIR, ANESTHESIOLOGY
NEWTON-WELLESLEY HOSPITAL
NEWTON, MA
provide excellent patient care. This focus is dem-
onstrated by surgical teams that use guidelines,
safety checklists, and standards of practice to
AORN Journal j 789
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provide safe care for every patient, every proce-
dure, every time.
The Association of Surgical Technologists (AST)
Recommended Standards of Practice for Patient
Identification, Correct Surgery Site, and Correct
Surgical Procedure was written “to provide support
to health care facilities in the reinforcement of
proper surgical patient identification and confir-
mation of the correct surgery site and procedure in
the perioperative setting.”29(p1) Additionally, AST re-
fers health care providers to The Joint Commission’s
Universal Protocol within each applicable accredita-
tion program standards manual for definitive guidance
on how to more accurately identify the correct patient,
surgical site, and procedure, as well as how to develop
and implement policies and procedures that support
safety practices.30
The time out is a procedural pause that surgical
teams continue to fine-tune to accurately verify
specific information that should be reviewed before
every procedure according to the role of each team
member. Examples of responsibilities of the certi-
fied surgical technologist (CST) in the first scrub
role regarding wrong-patient, wrong-site, and
wrong-procedure protocols include
n verifying the procedure to be performed and the
challenges it specifically poses,
n verifying that the surgical site is marked and the
mark is visible,
n confirming that implants are available for the
procedure,
n checking that needed instruments are available
for the procedure, and
n verifying that all required additional equipment
is available for the procedure.
Surgical teams routinely perform the time out
before the incision; however, some surgical teams
have begun using an extended, or double, time-out
process during preinduction while the patient is
awake and with all team members present and
again postinduction before the surgical phase be-
gins with all team members present. The two
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TABLE TALK
additional checks of an extended time out have
been shown to address patient safety concerns
related to extended operative times during ro-
botic surgery.31
There are also examples of high-functioning
teams that use debriefing or time out at the end of
the surgical procedure.32 This provides an oppor-
tunity for team members to reflect on the portions
of the procedure that ran smoothly and to identify
areas for improvement before the next procedure
begins. Research has shown that teams that en-
courage participation from all members function
more succinctly and efficiently.33
A quality patient safety routine must include
the consistent practice of the time out by all sur-
gical team members. This can be challenging
because, as surgical procedures continue to change
and improve, the surgical team must proactively
address and revise time-out procedures to comple-
ment the surgical intervention and ensure quality,
safe surgery for all patients. The goal is for each
service area represented on the surgical team to
use the same time-out practices for every surgical
procedure. To meet this goal, any amendments to
the checklist process must be modeled by surgical
team members to help ensure follow-through with
implementation. A cohesive approach to the time out
should help team members maintain their focus on
the individual patient and his or her safety.
SHERRI ALEXANDER
CST, FAST
CLINICAL EDUCATOR
MANAGER, CENTRAL STERILE PROCESSING
PAST PRESIDENT, ASSOCIATION OF SURGICAL
TECHNOLOGISTS
FRANCISCAN ST FRANCIS HEALTH
INDIANAPOLIS, IN
KATHERINE B. LEE
CST, RST, MS, FAST
PROFESSOR AND DIRECTOR, SURGICAL
TECHNOLOGY PROGRAM
RICHLAND COMMUNITY COLLEGE
DECATUR, IL
TABLE TALK
2014 Award for Excellence recipient’s perspective
Atul Gawande, MD, MPH, captured the reality of
the complexities in the surgical environment by
stating, “In surgery, you couldn’t have people who
are more specialized and you couldn’t have people
who are better trained. And yet we see unconscio-
nable levels of death [and] disability that could
be avoided.”34 On July 1, 2004, The Joint Com-
mission implemented mandatory adoption of the
Universal Protocol for accredited surgical facilities
in the United States,35 and, in June 2008, the World
Health Organization (WHO) premiered the WHO
Surgical Safety Checklist intended for global
application as a method to ensure safety protocols
and processes.36,37 The Joint Commission has re-
ported that wrong-site surgery continues to occur at
an alarming rate of 40 times weekly in the United
States.20 The difficult question is this: why have
checklists not resulted in eliminating the egregious
outcome of the seemingly preventable error of
wrong-site surgery?
Application and implementation of checklists
are more than just ticking the box on a page.38
Documented checklist compliance and adherence
are essential issues that need further research. If the
items on the checklist are not clear to the team that
is responsible for implementation, shortcuts will be
taken. There are identified barriers in the literature
that may be used as a tool for increasing managers’
awareness of these barriers and to address and offer
solutions that minimize the risk of wrong-patient,
wrong-procedure, and wrong-site surgery. Exam-
ples of barriers that prevent appropriate checklist
implementation include
n duplication of check points,39,40
n lack of communication,40
n inappropriate clinical application,40
n timing,39,40
n ambiguity of items,40
n staff/team hierarchy,39 and
n gaming (eg, completing or checking boxes of a
checklist before instead of during the time out).40
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Future research should include investigation
of the level to which health care providers en-
gage in practices related to safety checklists
(eg, compliance), checklist implementation, and
checklist redesign.41 For example, as a doctoral
student at Washington State University, Spokane,
I am researching the application of standardized
processes for surgery scheduling that begin at the
time of scheduling with the purpose of decreasing
surgical procedure scheduling errors. The intent of
this research is to stress that verification of infor-
mation at the time of scheduling is a critical
component that is often missed. Preventing sched-
uling errors is a matter of having policies and
procedures for processes that support getting it
right at the beginning of the scheduling process for
every patient.
As we commemorate the 10th anniversary of
National Time Out Day and moving patient safety
forward, it is important to recognize that patient
safety is a joint responsibility and commitment
for every member of the perioperative team. A
continual theme for successful checklist imple-
mentation intended to prevent patient harm is
“decisive and effective leadership, encouraging
active staff participation and educating individuals
utilizing the checklist.”42(p6) As team leaders,
perioperative nurses are critical for the support
and correct use of the surgical checklist, which
requires full engagement from every member of
the team.43 The nurse’s role is an essential com-
ponent of preventing wrong-site surgery, because
it is the perioperative nurse who advocates patient
safety for every patient, every procedure, every
time.
DONNA S. WATSON
MSN, RN, CNOR, FNP-BC
PAST PRESIDENT, AORN
STUDENT, PhD PROGRAM, COLLEGE OF
NURSING
WASHINGTON STATE UNIVERSITY
SPOKANE, WA
AORN Journal j 791
June 2014 Vol 99 No 6
AORN perspective
In 2000, the Institute of Medicine published the
report To Err Is Human: Building a Safer Health
System, which opened the issue of medical errors
to public debate and identified national, state, and
local policy directions for a safer health care sys-
tem capable of reducing medical errors and im-
proving patient safety.5 In the introduction to this
“Table Talk,” Ms Guglielmi has referenced many
of the initiatives focused on patient safety that
AORN has launched or collaborated on during
the past 10 years in response to the 1999 report.
Despite these activities, it is reported that 40
wrong-patient, wrong-site, wrong-side, and wrong-
procedure surgeries occur weekly in the United
States.20 These data identify why AORN continues
to expend resources on this safety issue.
Wrong-patient, wrong-site, wrong-side, and
wrong-procedure surgeries are “never events” that
should never happen.44 Implementing evidence-
based, risk-prevention strategies, such as the time
out, to identify and verify the correct patient, sur-
gical site, and procedure will reduce the risk of
error. Implementation of a checklist alone, how-
ever, will not achieve the long-term results nec-
essary to establishing a safe patient-centric
perioperative environment. AORN recognizes that
the foundation for improving patient safety during
all surgical and other invasive procedures must start
with a commitment to establishing a strong safety
culture. Weaving a culture of safety into the fabric
of the organization requires members of leadership
to allocate resources and provide incentives or
rewards for promoting adoption of the required
changes.12 These efforts also require the support
of the entire perioperative team so that everyone
feels respected and accountable.45,46 Furthermore,
a safety culture must maintain zero tolerance for
disruptive or intimidating behavior when a team
member attempts to implement a safe practice, such
as the time out. AORN supports that safety must be
valued as a top priority, even at the expense of
productivity.12
792 j AORN Journal
TABLE TALK
Why is it important to continue to focus efforts
on the time out? There are few more devastating
statements in the care of surgical patients than
“there’s been a wrong-site surgery.” For patients
and their families, a wrong-side, wrong-site, or
wrong surgical procedure is life changing and may
have a devastating outcome. For the surgical team
and facility administrator, a sentinel event such as a
wrong-site surgery is profoundly demoralizing to
the spirit, can be a career-changing experience, and
is damaging to the facility’s reputation.
There are centers of excellence in which the
checklist, including the time out, is embraced and
implemented as part of the preoperative routine.
However, the frequency with which wrong-site
surgery occurs suggests that these centers are not
representative of the majority of facilities in the
United States. As Dr DuPree discusses, the Joint
Commission Center for Transforming Healthcare’s
project on wrong-site surgery demonstrates what
targeted efforts in decreasing wrong-site surgery
can accomplish. Such efforts also demonstrate that
full implementation takes timedtime for the peri-
operative team to get it right and for all units in
an institution to get on board.8 There are several
suggestions offered in this article that provide ways
to be vigilant and proactive in monitoring results of
safety measures after their implementation.
One question left unanswered is this: how can
we instill a strong sense of accountability and re-
sponsibility in every team member to use all avail-
able measures in protecting every patient, every
procedure, every time? Dr Leape has spoken to the
issue of mandating that the surgical safety checklist
be required for all surgical procedures.8 Regulation,
according to Dr Leape, works best when a practice of
unquestioned value has become the norm. He sug-
gested that the process of checklist adoption needs
to be greatly accelerated and that what should be
mandateddand nationally fundeddare large-scale
state and system-wide collaboratives to motivate, train,
and support local efforts to implement checklists.8
TABLE TALK
AORN’s mission is to promote safety and op-
timal outcomes for patients undergoing operative
and other invasive procedures. We are ready to join
in the national effort as identified by Dr Leape.
Meanwhile, AORN will continue our strong advo-
cacy and protection for every patient, every pro-
cedure, every time.
LINDA K.GROAH
MSN, RN, CNOR, NEA-BC, FAAN
EXECUTIVE DIRECTOR AND CHIEF EXECUTIVE
OFFICER
PAST PRESIDENT, AORN
AORN, INC
DENVER, CO
Editor’s notes: The Universal Protocol for Pre-
venting Wrong Site, Wrong Procedure, Wrong
Person Surgery is a trademark of The Joint Com-
mission, Oakbrook Terrace, IL. The Targeted So-
lutions Tool and the TST are registered trademarks
of the Joint Commission Center for Transforming
Healthcare, Oakbrook Terrace, IL.
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