A time-out is not a time-out unless all members of the surgical team are present, proactive and participate. Require a spoken response from each team member: circulator, surgeon, anesthesia, scrub tech and any additional ancillary staff present during the case. The circulator confirms the patient's identity by the name tag on his wrist, and all verbally state confirmation. The nurse calls out the correct site and procedure, and all again orally confirm. Active participation means not mindlessly nodding so that they can get on with the case already. You want everyone taking their positions around the bed and identifying themselves by name (see "Embroidered Scrub Caps Make Close-Knit Teams" here).

How do you guarantee your staff participates with the surgical time out? For starters, you must get their attention, which is difficult to do during the busy few minutes before a procedure. Everyone must stop what they're doing and be mindful, engaged and focused on patient safety before the incision. Colorful reminders certainly help, products like checklists, posters, bags, stickers on syringes, hoods that cover the scalpel, reminder sleeves on the Mayo stand, cloths placed over the instrument tray or near the surgical site. For you do-it-yourselfers, here are a few more creative ideas to get the team's attention:

• Spell it out in big red letters. Staff at Regions Hospital in St. Paul, Minn., cover the instruments for each case with a time-out towel to remind the OR team to stop for a time-out before making the first incision. Hospital personnel designed the towels in response to a wrong-site surgery at the facility.



• Bang the gong. A 14-inch-wide Tibetan gong hangs in each of the 24 operating rooms, endoscopy suites and cath labs at St. John Macomb-Oakland Hospital in Warren, Mich. When the recorder strikes the wall-mounted gong, it commands the OR team's attention and sets the intention for a proper time out before every procedure. The gong is available in office-supplies catalog for about $75.



• Blow the kazoo. On a whim, Barbara Harvey, RN, of the Fredericksburg (Va.) ASC, bought a kazoo to announce time-outs. It worked, she says, and thoroughly entertained the nurses, techs and (some of the) surgeons. She no longer uses the kazoo before every case, but it sits in her locker, just in case.

Team compliance

Surgery is a team sport. It does little good if your nurses conduct time-outs off in a corner by themselves without surgeons, anesthesia and the rest of the staff — some of whom could be indifferent and view time-outs as just another "nursing thing" that doesn't concern them. The real danger is documenting on the chart that a timeout had occurred, even though half the team didn't participate.

An effective way to enforce team compliance and maintain structured time-outs is to make one person responsible for initiating the timeout. In most ORs, it's the circulating nurse. When we polled our readers to find out who initiates the time-out at their facility, 79% said the circulator and 10% said the surgeon. Another 10% said it varies — sometimes it was the anesthesiologist, sometimes the surgeon, sometimes the nurses. This inconsistency is dangerous.

Similarly, there's a time (before the incision is made or procedure begins) and a place (the OR) when you should take a timeout. Not in pre-op/holding, not immediately after intubation and not as soon as the surgeon walks in the OR. No, the best time to perform a timeout is before induction or sedation. Safety experts say letting the patient actively participate in the time-out adds another layer of protection.

What happens when nurses express a concern during a time-out, but don't think the surgeon is taking them seriously?

While experts say it's ok to conduct an informal timeout in the pre-op area to go over surgical and anesthesia consents, and complete all pre-op screening requirements, nothing can replace a formal timeout with the entire team before sedation or analgesia. Same goes for a regional block or a fire timeout — they're adjuncts to the main timeout.

A second time out?

Not taking a second time out when a different surgeon performs a different procedure on the same patient is a leading cause of wrong-site surgery, says the Joint Commission. But what about when multiple procedures require position change and re-draping on the same patient by the same team? For example, you move a patient from supine into prone position, and the patient's left leg is now on his right side. Or the shoulder is closed and the knee still needs to be fixed. Should you conduct a separate time-out?

Yes, says Katherine L. Kirkham, MSN, RN, CNOR, of the University of Florida Health-Shands in Gainesville, Fla. "To minimize confusion and the potential for wrong-site surgery after you reposition a patient," she says, "take a 'pause' or a mini time-out to confirm the procedure, the surgical site and the marking."

Captain of the ship

The surgeon's participation is absolutely critical. "When time-outs and other features of potentially effective surgical checklists fail —resulting in preventable, often harmful errors — studies indicate that the behavior of senior surgeons is often a factor," writes Nancy Berlinger, PhD, and Elizabeth Dietz in the AMA Journal of Ethics.

If nurses or staff express a concern during the time-out, but don't think that the surgeon is taking their concerns seriously, they may stop expressing these concerns, add Dr. Berlinger and Ms. Dietz.

"The surgical time-out is a strategy that, in part, is designed to support personnel often seen by some as subordinates — such as nurses, students and resident physicians — in their roles in maintaining patient safety, as well as to prevent harm by compensating for difficulty of speaking up in hierarchical environments and challenging one's own supervisor or other superior in those environments." OSM