June 8 is National Time Out Day
The Association of periOperative Registered Nurses (AORN) and The Joint Commission created National Time Out Day to remind surgical teams to pause before operations to confirm the correct patient, procedure, and site, as well as perform other important safety checks to prevent wrong-patient, wrong-procedure, and wrong-site surgery.
Here are some resources, articles, and safety stories to help you and your team recommit to safe surgery and raise awareness about this powerful safety practice.
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Wrong-Site Surgery in Pennsylvania During 2015–2019
Patient Safety Authority Learning Management System (LMS)
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Wrong–Site Surgery: Does That Really Happen?
By Robert A. Yonash, RN
Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities
By Robert A. Yonash, RN & Matthew A. Taylor, PhD
Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications
By Lea Anne Gardner, PhD, RN
Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers
By Lynette Hathaway, MSN, RN, Shawn Kepner, MS & Rebecca Jones, MBA, RN
Health Information Technology–Related Wrong-Patient Errors: Context is Critical
By Tracy S. Kim, BA, Jessica L. Howe, MA, Ella S. Franklin, MSN, Seth Krevat, MD, Rebecca Jones, MBA, RN, Katharine T. Adams, BA, Allan Fong, MS, Jessica Oaks, MIT & Raj M. Ratwani, PhD
Safety Tips for Patients
Aubrey Simpson, RN - Forbes Hospital, Allegheny Health Network
Before surgery, it’s important to confirm that everything is right: the right patient, the right procedure, and the right area. That was particularly applicable in one case where the patient was marked for a procedure on their right side and the consent forms named the right side—but the operating room schedule and electronic health record (EHR) indicated the patient’s left side. When Aubrey Simpson, a registered nurse at Forbes Hospital, Allegheny Health Network, discovered the discrepancy she notified the surgeon and they determined that there was a scheduling error. Then two nurses, a certified registered nurse anesthetist, the surgeon, and the patient confirmed that the correct side was the right side, and the surgery was performed on the correct side. This illustrates the impact of the time-out: Everyone doing the correct thing and initiating a focused verification assessment before the procedure helped ensure the safety of this patient.
Lindsay Kreutzer, PharmD - Forbes Hospital, Allegheny Health Network
Lindsay Kreutzer, a trauma and critical care pharmacist at Forbes Hospital, Allegheny Health Network, was reviewing a patient’s chart when she noted that they had a rib plating surgery listed for the next day. This didn’t make sense: the patient didn’t have broken ribs. Investigating further, Lindsay discovered another patient on the same service was supposed to have a similar procedure that day—but their chart showed no procedure was scheduled. She made the advanced practice providers aware of the mix-up, and they called to make the correction. How did this happen? The first letter of both patients’ last names was identical, and they had been in adjoining rooms the day before—most likely when the surgery was scheduled.
Brianna Thompson, PharmD, BCPS, BCCCP - UPMC St. Margaret
In her role as the clinical pharmacy specialist in critical care at UPMC St. Margaret, Brianna Thompson improves the delivery of safe patient care every day. In a recent good catch, Brianna was completing an admission medication history for a patient who was in the process of being admitted to a medical/surgical unit. She noticed the presence of a continuous prostacyclin infusion device (treprostinil) for this patient—which could have put the patient at risk if they were admitted to a med/surg unit lacking the appropriate level of monitoring. Brianna worked with the admitting ED physician and admitting primary service to change the patient’s admission plan and level of care to ensure the patient received the proper level of monitoring should the continuous prostacyclin device malfunction while they were in the hospital. Brianna received the I AM Patient Safety 2021 Safety Story Award in recognition of this and other vigilant efforts to reduce potential harm to patients.