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Our regional anesthesia schedule is often jam-packed. But even during the busiest days, when we perform as many as 25 blocks, we've never had a patient safety breach. So you can imagine our surprise when we almost started a wrong-site block during a slow day, when we had more than enough time to confirm the correct site on the correct patient before the correct procedure. That near-miss served as an important wake-up call: We acted quickly to revamp our time-out process so a similar oversight would never happen again.
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The Essential Elements of a Time Out |
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This is the time-out process we use before the start of every regional block performed at our facility. The specifics will depend on the types of procedures you host, but these 5 steps should be a part of any effective time-out protocol. Use them to guide the script your staff uses before each and every case. 1. Two patient identifiers. Ask the patient to announce his name and birth date. 2. Verification of the wristband and chart. Have nurses check the patient's wristband and chart to make sure the name and birth date match on both. The block provider (or surgeon) should confirm the patient's name on the ultrasound or surgical documentation, while the anesthesia provider should verify that the patient's name on the chart and consent forms match. 3. Identification of the site and side. The anesthesia provider should ask the patient to announce the planned procedure. The nurse then confirms that the surgeon's or anesthesia provider's initials are marked at the proper site. Finally, the nurse and the anesthesia provider verify the patient's name and the procedure against the OR schedule. 4. Verification of procedure and position. The resident or surgeon confirms that the ultrasound or surgical documentation lists the proper procedure. Likewise, the anesthesia provider confirms that the procedure is listed correctly on the surgical and regional block consent forms. The anesthesia provider and the resident then confirm that the patient is in the proper position for the block or procedure. 5. Verification of equipment and special requirements. The entire surgical team makes sure that all needed equipment is in the room. The nurse asks the patient to alert the team of any allergies he has and announces the patient's blood coagulation test results (if the patient was on blood thinners). If the patient is a woman, the nurse reads the results of her pre-op urine pregnancy test. — Melinda Shafer, RN |
"Let's begin the time out."
In the weeks after the error, we developed a scripted time out based on the guidelines of the Joint Commission, New York State Department of Health, World Health Organization and my facility, the University of Rochester Medical Center (see "On the Web").
The block team, which includes a registered nurse, the anesthesia provider and the block provider (usually a resident), works with the patient's family while starting and completing the pre-block time out. Including patient escorts in the time out is important because it puts the patient at ease and encourages the patient and family members to speak up if they believe something is wrong.
Before the time out begins, the anesthesia provider initials the site of the regional blockade. The anesthesia provider and the nurse then put the patient in the proper position for surgery. Our nurses play an integral part on the block team. Besides their traditional roles as patient advocate and educator, they're in charge of calling for the time out.
We built a couple of fail-safes into the front and back end of our time-out process:
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Work Ahead to Prevent Errors |
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When you run a high-volume surgical facility with quick case turnarounds, the risks of wrong-site surgery are increased. This is especially true in fast-paced ophthalmic surgery centers. Over the years, we've had a number of near-misses that made us look for ways to head off wrong-site errors before patients even walk through our doors. Work ahead to prevent errors on the day of surgery. Improve your relationships with surgeons' schedulers so that you get patient information in-house as soon as possible. Then schedule pre-op phone calls with patients to verify the procedure and surgical site. When one of your nurses calls a second time to gather the patient's medical history, she should again confirm the surgical site and procedure. If you find errors in the documents that you receive from a physician's office, work with the scheduler to rectify the issue. It can be tricky to fix a problem that isn't yours without inflaming the relationship, but you can work out creative solutions. For example, we work with an eye practice that faxes us a copy of the patient's intraocular lens measurement right after the patient is measured. That way we have documentation of the correct eye straight from the person who measured the eye in the physician's office. We also work with a surgeon who brings his own patient records to the surgery center so he can double-check them against our documentation. In the end, it's worth the effort to root out documentation errors before the patient arrives in the operating room, or better yet, your surgical facility. Experiencing a near-miss during a time out can upset the surgical team and, more importantly, the patient. — Jovanna Grissom, BSN, CASC Ms. Grissom ([email protected]) is chief operating officer of the Las Vegas-based ProMed Management Group, which manages a pair of surgery centers in Nevada. |
- All present and accounted for? The time out cannot start until every member of the block team is in the room, has stopped what they're doing in order to focus entirely on the discussion at hand and verbally confirms that they're ready to review the particulars of the case.
- All in agreement? The time out cannot end until everyone agrees on the correct surgical site, procedure and patient identity. The time out stops immediately if someone doesn't agree on any of those points, if there's a discrepancy in the surgical documentation or if someone enters or leaves the room while the time out is in process. If there's disagreement or issues arise, the concerns are addressed and rectified before the team restarts the time out from the beginning. While starting the time out from the beginning may sound like a lot of steps to repeat, it's not. It only takes about 45 seconds.
Once the team has completed the time out's required steps (see "The Essential Elements of a Time Out"), the nurse asks: "Does everyone agree?" Although each team member has already had the chance to point out discrepancies, the nurse gives everyone a final opportunity to speak up. If the team agrees, the resident is handed the medication and equipment for the block. If the anesthesia provider orders medication, the nurse administers it. The resident then begins the block. If someone doesn't agree, if someone leaves the room or if another person has come into the room during the time out, the process stops.
Although it took some work to develop our new time-out script and train staff on how to use it properly, the block team's effort has been worth it: We haven't had a block error since. The time out script also helps reassure patients that we're doing everything possible to protect them from wrong-site or wrong-block errors.
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On the Web |
Download a printable version of the University of Rochester Medical Center Surgery Center's time-out script at www.outpatientsurgery.net/resources. |
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