Time-outs were put into place several years ago by JCAHO due to the alarming number of wrong site surgeries taking place. Wrong-site surgeries are considered “never events,” which are obviously events that should never happen.
Time-outs occur right before a procedure, during which the procedure team is supposed to go through a check list to make sure all is ready. Verras was asked to examine a hospital’s compliance with its time-out policies in the wake of three never events occurring in the space of 10 months. Here is what we discovered, based upon a review of hundreds of procedures in 18 procedure locations.
- While time-outs were being conducted (and had been since 2002), the process was not being done consistently. Not all items on the checklist were always being reviewed
- There would frequently be distractions during the time-out, such as music playing
Our analysis began in the fall of 2011. This analysis included gathering data on non-compliance. In the four months from the time we initiated the analysis, there were 31 procedures where there was some type of non-compliance to the time-out policy, for a non-compliance rate of 2.5%. While that number may seem small, it is not. Also, while compliance data was not recorded prior to our beginning the analysis, we believe the fact that since clinicians knew they were being monitored, compliance went up, and that non-compliance prior to our analyzing the processes was even higher than 2.5%.
After examining the data and working collaboratively with the medical staff, the following physician-directed best practice protocol was implemented.
- The procedure and tracking form were revised.
- Concentrated education was done for staff and physicians.
- Ongoing monitoring was put into place in the OR and throughout the facility to monitor every location where time-outs were being done.
- A process was put into place which called for the CMO, chief of staff, and/or chief of OR to meet individually with any physician or staff not following the procedure.
In the two months after the new process was formally introduced, there were two incidents of non-compliance out of a total of 661 procedures, for a non-compliance rate of 0.3%. Neither incident resulted in a never event. In addition, there were two (2) potential wrong site procedures caught and avoided with the revised time-out process.
There is a new energy and effort around this process. It is now being taken very seriously and all members of the team are feeling more empowered to speak out.
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We welcome your insight on time-outs. Please feel free to comment. And remember…June 16 is National Time-Out Day.