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    How surgical time-outs may (or may not) lower litigation risk

    Adherence to WHO Surgical Safety Checklist can help reduce risk of error

    Brianne Goodwin, JD, RNBrianne Goodwin, JD, RNA 66-year-old female was scheduled to undergo computed tomography-guided renal cryotherapy for localized kidney cancer. During a preoperative visit with anesthesia, a note was made in the allergy section of the chart stating: “IV contrast dye.” Preoperative documentation suggested that hydrocortisone should be used before surgery, but no order was written for this.

    On the day of surgery, the attending anesthesiologist expressed concern about the severity of the reported allergy, and intended to discuss it with the attending urologic surgeon. On the day of the procedure, the anesthesiologist induced local anesthesia and conscious sedation, and then left the room to oversee another patient requiring induction of general anesthesia, leaving behind his anesthesia resident.

    Also by Brianne Goodwin, JD, RN: How patient obesity can impact malpractice litigation

    In the OR, the patient was surrounded by the urologist, two urology residents, a medical student, nursing and surgical tech staff, and the anesthesia resident. A surgical “time-out” was conducted, during which a nurse raised concern about the alleged IV contrast allergy. Everyone in the room turned to the anesthesia resident for information. Ultimately, the decision was made to administer the prophylactic hydrocortisone and proceed. The anesthesia attending returned to the room after the time-out, frustrated that he had not been part of it. Further, he had concerns that his resident lacked confidence to speak up and address the allergy concern himself.

    The question: Did the surgical “time-out” serve its intended function? Can you identify ways the “time-out” should have been done differently or worked better?

    Time-out’s efficacy subject of debate

    The elimination of wrong-site surgeries was made a National Patient Safety Goal in 2003 by the Joint Commission and requires compliance with a Universal Protocol consisting of three steps: proper preoperative identification of the patient by three members of the team, marking the operative site, and a final “time-out” just prior to the surgery or procedure regardless of where it is being performed.

    Despite the intention of the Universal Protocol, debate swirls around the efficacy of it, particularly the time-out portion, as there is little evidence of its efficacy in preventing wrong-site surgery (bit.ly/AHRQtimeout). In fact, in 2007, a urologist removed a healthy kidney rather than the diseased kidney from a 55-year-old patient and in 2016, a surgeon removed a kidney from the wrong patient altogether.

    In the 2007 case, diagnostic imaging was not rechecked to see which kidney had a cancerous mass. In addition, the images were available on a small computer screen in the OR, but were several feet away from the surgeon and could not be seen. Even the most perfectly run time-out may not mitigate a failure to follow basic policy or procedure. In the 2016 case, the kidney was removed from a patient with the same name as the patient who should have had a kidney removed. A time-out hopes to catch errors such as patient misidentification, but will not do so if the team only states patient name, and omits date of birth, medical record number, or other specific patient identifiers.

    Adverse events resulting from surgical procedures are more frequently related to errors made before or after the surgery than by technical surgical mistakes during the procedure (bit.ly/WHOchecklist). When one pauses to consider this, it is daunting to think of the number of people involved in preoperative surgical scheduling, booking, and communication with the patient; not to mention postoperative diagnosis and treatment. A breakdown anywhere along the line that leads to an adverse outcome can lead to litigation that would undoubtedly include the surgeon, even if no surgical error was made. After all, how effective is a time-out if the surgical scheduler books the wrong procedure and the team relies on that?

    Next: Three opportunities to reduce error risk

    Brianne Goodwin, JD, RN
    Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.

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