New Tool from the Joint Commission to Improve Surgical Consultations

Community hospitals were 3.68 times (range, 1.31-10.31 times) more likely than other facilities to permit site marking performed only by the attending. Most respondents operating at children’s hospitals (84.4 percent) were satisfied with their hospital’s site-marking and surgical checklist policies for pediatric otolaryngology procedures (87.1 percent). Twenty-one percent of survey respondents reported involvement in a wrong-site surgery at some point in their careers.

“There is a dynamic tension between universal, national mandates and allowing local variation to encourage hospitals to tailor policies to unique needs,” the authors concluded. “Further study is needed to determine if the observed variations are beneficial or harmful.”

Best Practices

Dr. Shah said it helps to have surgeon champions who are proactive in implementing the safety goals set forth in the Joint Commission’s Universal Protocol. “The more champions you have advocating” for the protocol, the more robust the time out process, he said.

Making the time out routine in every case “significantly adds to the safety of the operating room,” said David J. Arnold, MD, FACS, associate professor of head and neck surgery at the University of Miami Miller School of Medicine. “We’ve changed our culture so that it is part of the whole experience. It’s what’s expected.”

In many hospitals, nurse-initiated time outs can help level the hierarchy and encourage surgical team members to speak up if something does not look or sound right, said Michael G. Glenn, MD, FACS, medical director and physician-in-chief at Virginia Mason Medical Center in Seattle, where he practices otolaryngology. By fostering an atmosphere in which members feel comfortable introducing themselves, “it gets everybody on a first-name basis, [and] we believe that helps create a culture where people are less afraid to raise important questions or concerns,” he said.

While use of the time out has decreased the number of errors, its effectiveness is compromised when only part of the surgical team participates. The timing of this event is also crucial to catching potential mistakes, and it should not occur after induction, prepping and incision, according to the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). “What is included and excluded in the verbal report has also been shown to be critical, as is whether the surgeon, as the leader of the team, gives the report or it is done by others on the staff,” wrote Phil Haeck, MD, the AAAASF’s former vice president of legislation, in the summer 2009 issue of The ASF Source, the association’s newsletter. “The real problem lies in the possibility that as this becomes mundane and repetitive, participants can shut out the verbiage, become inattentive and lose the real value of the work stoppage. Error rates have crept back up in some institutions, especially when the technique is not rigidly adhered to.”