National Time Out Day 2012

June 13th, 2012


By , BSN, RN

Take a “Time Out.” Today, June 13, 2012, is National Time Out Day. Now surgical nurses immediately know what that means. However, “time out” has spread far outside hospital operating rooms and now many procedures, invasive or not, require the staff to participate in a formal “Time Out” before getting started.

This is the ninth National Time Out Day since the Association of periOperative Registered Nurses (AORN) launched this initiative in 2004. The idea grew out of the Patient Safety First program developed in 2002 in response to the Institute of Medicine’s report To Err is Human: Building a Safer Health System.

Buy In

As the idea for a formal “time out” procedure grew, so did support. AORN called on the Joint Commission as well as the American College of Surgeons (ACS); American Society of Anesthesiologists (ASA); American Society for Healthcare Risk Management (ASHRM), and the American Hospital Association (AHA), along with a dozen other organizations to endorse the movement. The first recognized “National Time Out Day" was June 23, 2004. In July, just a month later, the Joint Commission began surveying institutions based on protocol guidelines for the now adopted Universal Protocol.

The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care, and office-based surgery facilities. The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations.

The Universal Protocol drew upon, expanded and integrated a series of requirements under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. The three principal components of the Universal Protocol include a pre-procedure verification, site marking, and a “time out.”

Outside the OR

In the last few years there has been a movement to require “time out” outside the operating room setting. There are a number of clinical reasons for a procedure to take place outside of an operating room. Patients having an invasive, high-risk, diagnostic or therapeutic procedure performed not in the operating room but in an office, procedural area, emergency department or at the bedside should be covered by this safety procedure as well.

This new type of protocol, while similar in process to safety measures used in operating room, takes into consideration the unique work of the different patient care areas listed, such as image-guided biopsies and procedures such as PICC line placement where the insertion site is not predetermined. It covers the processes of patient consent; identification; verification of procedure, site, and patient; and the indications for site marking.

When to “Time Out”

According to Joint Commission guidelines, "Time out" is immediately before starting the procedure. It is conducted in the OR/procedure room before the procedure/incision. It should involve the entire operative team, use active communication, and be briefly documented, such as in a checklist. It is left up to the organization to determine the type and amount of documentation involved. The “Time Out” must include:

  1. Correct patient identity.
  2. Correct side and site.
  3. Agreement from entire team on the procedure to be done.
  4. Final verification of the site mark should take place during the "time out."

The hospital/organization may, in conjunction with the hospital staff, create processes that are not specifically addressed in the “time out” to establish a standardized protocol for patient safety. There should be processes and systems in place for reconciling differences in staff responses during the "time out."

In 2008, David Feldman, MD, MBA, wrote a commentary for the Agency for Healthcare Research and Quality (AHRQ) titled “Inside of a Time Out. He addressed several interesting points. For example, the exact manner in which the time out is conducted varies considerably from institution to institution.

”In some organizations the time out occurs just prior to anesthesia induction, since it is at that time that the anesthesia team is most tuned in to that patient's particular needs,” Feldman writes. “Unfortunately, in many teaching facilities, the surgical attending may not yet be physically present, and performing the time out at induction leaves potential for error between induction and incision.”

It is for this exact reason that New York State requires the “time out” take place immediately prior to the incision, a practice performed in many other institutions across the country as well.

Now the issue at hand when waiting is that while the whole surgical team is now present, the anesthesia attending may now be gone because he or she is covering more than one OR. There are a couple of possible problems now, either the patient is asleep and the team waits for the anesthesiologists return (costly for both the patient and the surgeon), and when the anesthesiologist does return they may not be thinking wholly about this patient but about the patient they just left.

Another issue he points out is that the Joint Commission requirements are fairly simple but may not include all the issues at hand. Many organizations are adopting an expanded “time out” procedure that includes everything from “is all the needed equipment in the room and operational?” to ensuring the administration of prophylactic antibiotics, and will there be a neutral zone a designated container used to pass sharps, rather than from hand to hand), and other important patient and staff needs depending on the procedure.

While the typical time out (whether limited or expanded) is essentially a checklist, there is some argument that maybe the questions should be more opened ended, allowing for unusual or unexpected circumstances. Some institutions have adopted a post-procedural debriefing to cover issue, which arose during the procedure.

The “time out” is a fluid, evolving instrument that has definitely led to greater patient safety. As the AORN says, this is an opportunity to closely evaluate and reassess your culture of safety – and consider whether everyone on the healthcare teams feels entirely free and obligated to speak up if they think anything is wrong.

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