Surgical Teams Take Time Out for Safety

Universal Protocol Prevents Operating Room Errors

June 21, 2004

Every year, more than 40 million patients are admitted for surgery at U.S. hospitals, while another 31 million undergo outpatient procedures.  In an effort to ensure that all of those patients receive safe operations, national organizations together with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has designed a simple, three-step process to ensure that the right surgery is performed on the right patient, every time.

As of July1, 2004, nearly 4,600 hospitals with JCAHO accreditation must begin using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.™   Creating a standard pre-surgical safety process is part of the JCAHO’s 2004 National Patient Safety Goals.  The universal protocol requires that hospitals:

  • verify that all relevant documents, x-rays, lab tests, etc. are available prior to the surgery, and that they have been reviewed and are consistent with each other.  Surgical teams are required to verify that each member of the team as well as the patient are in agreement on the procedure to be conducted and the exact site of that surgery.
  • clearly mark the incision site in a way that will be visible even once the patient is prepped and draped.
  • take a “time out” immediately before starting the procedure to perform a final check to make sure that the correct patient is about to undergo the correct procedure, on the correct site. 

To help promote the adoption of this protocol, the Association of periOperative periOperative Registered Nurses (AORN) is sponsoring a National Time Out Day on June 23, 2004.

“The Time Out gives each member of the team one last chance ask questions or clear up any inconsistencies that may appear,” said Sandra Monacelli, R.N., interim nurse manager of the Operating Room at Strong Memorial Hospital.  “In a busy operating room, this pause can mean the difference between a safe surgery or a serious error.” 

Strong Memorial has been in full compliance with this protocol for about a year.  In fact, a Strong orthopaedic surgeon Kenneth DeHaven, M.D., was part of a national task force of the American Academy of Orthopaedic Surgeons that first recommended that surgeons sign the site of their surgery back in September of 1997. 

“These steps have been an important part of Strong’ commitment to patient safety and it’s great to see these and other safety practices adopted nationally,” said Robert Panzer, M.D., chief quality officer at Strong Memorial.  “We owe it to every patient to take all steps necessary to prevent needless and potentially devastating medical errors.” 

The Joint Commission evaluates and accredits nearly 16,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care. Since 1951, JCAHO has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks

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Teri D'Agostino
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