5 Ways to Improve a Time Out Together

Publish Date: May 8, 2019

Estimates still suggest 40 to 60 wrong site surgeries occur each week in the United States.

Despite years of work to help perioperative teams improve their adherence to all elements of the Universal Protocol through collaborative education and national awareness through events such as National Time Out Day, marking its 15th anniversary this year, the needle has not significantly moved in reducing wrong site surgery (WSS).

Sentinel event data of adverse events reported to The Joint Commission through 2018 still put WSS in the top three most commonly reported adverse events, a similar ranking WSS has held for the last five years.

Staying Vigilant as a Team

Preoccupation with failure is one important principal of high reliability that LuAnn Vis, RN, BSN, MSOD, associate director of High Reliability Initiatives within the Joint Commission’s Center for Transforming Healthcare knows can make a difference in preventing WSS.

“Every member of your perioperative team, including those involved in scheduling and preop where WSS risks often crop up, needs to be vigilant to look for risks that could lead to error,” Vis says. “If you do not understand your risks and take time to address them, then it is by chance that a wrong site surgery has not happened yet in your surgical setting.”

Taking a Time Out is the critically important culmination of safety work completed in concert prior to the Time Out, including during scheduling and preop, to ensure a safe surgery for every patient, Vis adds. “The worst thing you can do in the OR is to allow the Time Out to become a rote process of checking boxes—the Time Out should be the last safeguard to raise concerns before incision to prevent permanent patient injury as a result of wrong site surgery.”

Understanding Wrong Site Surgery Risks

Orthopedic surgeries garner the highest number of wrong site surgeries, followed by dental and spinal surgeries. Laterality (mistaking wrong side for surgery, such as left leg instead of right leg) continues to be the top reported type of wrong site surgery.

These latest sentinel event data suggest three primary root causes for WSS:

  1. Human factors issues, such as staffing, education, competency, lack of team work, team communication and team training.
  2. Leadership failures, such as allowing hierarchy issues among surgical teams, establishing policies but failing to educate on the policies and failing to create a safety culture in which every staff member is obligated to voice safety concerns.
  3. Communication errors among all team members, including between and among physicians and staff during verbal, written and electronic orders.

Research suggests that initial risks that can lead to WSS are often introduced early on in a patient’s course of care, long before the Time Out. Scheduling is one high-risk episode of care for WSS when communication breakdowns and incomplete and poor documentation practices such as misuse of abbreviations occur.

The preop area is another risky area, especially if the anesthesia block is placed here and fewer standardized practices for patient verification and the Time Out are in place.

These risks can easily be missed once the patient enters the OR.

Add in the inherent distractions in the OR, potential rushing to make up time, and possible siloed roles that often keep members of the team from fully engaging in the Time Out, and you create a perfect storm for WSS to occur, Vis suggests. “One final safeguard against wrong-site surgery is making sure every team member feels safe speaking up with a concern during the Time Out. Without a safety culture driven by leadership to acknowledge and respond to team members voicing concern, silence will be the final risk that allows a wrong-site surgery to occur.”

Ensuring a Safe Time Out

Many factors contribute to ensuring the most effective Time Out. Vis notes five important ways to ensure a Time Out is strong and effective.

  1. Assess Unique WSS Risks—Critical in scheduling and pre-op, as well as the OR, make sure any policies initiated to standardize practices in these settings include regular education for all. Use a standardized tool, such as The Joint Commission’s Safe Surgery Targeted Solutions Tool® to identify and respond to the risks in a system.

  2. Involve the patient—A preoperative briefing provides valuable time to verify with the patient the identifiers, procedure, site and side prior to the Time Out. The value of this patient-centered approach in which patients are empowered to be active participants in their care is becoming more recognized. When confirming surgical site and other important aspects of a procedure, explain why you are involving the patient and reiterate to the patient that his or her safety is the number one goal.

  3. Make it a Role-Inclusive Time Out—If everyone has a part to play in the Time Out, then everyone must be engaged in the Time Out. This gives every surgical team member an opportunity to confirm patient information, including surgical site, and raise a “red flag” if they have a concern. Templates for tailoring your own Time Out such as AORN’s Comprehensive Surgical Checklist give teams the opportunity to provide each team member a specific responsibility during the Time Out.

  4. Measure Time Out Success—Regular observation of the Time Out can identify inconsistencies and areas for improvement. Observation can also help identify teams that have perfected their Time Out engagement and share their process with others through department-wide educational opportunities.

  5. Instill a Strong Safety Culture—The safety culture leadership initiative is an area that should always be improving. Empowering staff members to speak up should be encouraged by leadership and presented as an obligation of professional practice for any role. Concerns should gain immediate response by leadership. Staff members need to witness evidence of quick response to ensure that their voice will be heard. This builds trust within the organization.


“Time Out cannot become routine, but, instead, must always include dynamic team engagement,” Vis stresses. “When a perioperative team works together to focus on risks that can lead to WSS, the Time Out becomes a critical last step to catch errors that may have slipped through the cracks. We aim for zero wrong site surgeries, always, and need to be vigilant every step of the way.”


Additional Resources

Review 2018 sentinel event data from The Joint Commission.

Learn more about The Joint Commission Center for Transforming Healthcare’s work to drive high reliability for Safe Surgery, including with the Safe Surgery Targeted Solutions Tool®

Free Resources for Members

Tool Kits

AORN’s Correct Site Surgery Tool Kit- Work with your team to review educational resources on implementing best practices for promoting correct site surgery. Plus, access AORN’s Comprehensive Surgical Checklist to tailor a role-inclusive Time Out in your OR.


Safe Surgery Begins with a Time Out- Register for the webinar replay to review case scenarios, the importance of team communication, and the use of a surgical safety checklist. (1 CH)

AORN Journal CNE Articles

Back to Basics: The Universal Protocol- Learn about the components of the Universal Protocol and some evidence-based strategies to implement it in practice. (1.4 CHs)

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