1. An Evaluation of the Process By: Nisha Estrada, RN
An evaluation of the Importance of Timeout Procedure and the Prevention of Errors
An Evaluation of the Process
By: Nisha Estrada, RN

2. The purpose of Time out
“The purpose of time out is to be a safety measure to prevent harm as a result of operating on the wrong patient, wrong site or performing the wrong procedure. Time out has evolved to include quality patient care and enhance performance of the surgical team”, (Pellegrini, 2017).

3. Reasons for focus on the topic
There is research that suggests that even with time out in place there still have been issues with errors and near misses occurring during procedures. For this reason this is why there needs to be focus on ways to help prevent these situations from occurring.

4. Medication errors Wrong procedures Wrong site errors
Some examples of errors that have occurred during procedures even when time out was implemented include:
Medication errors
Wrong procedures
Wrong site errors

5. Medication errors occur in 1 in every 133 operation
Medication errors occur in 1 in every 133 operation. (Healthline News Article, 2015)
Medication errors cause at least one death every day and injury approximately 1.3 million people annually in the U.S. (U.S Dept of Health and Human Services, 2016)
Every 1 in 113,000 of surgical cases is wrong site surgery cases. (Agency for Healthcare and Research and Quality, 2008)
1 in every 20 medications given are given in error (Study done in Massachusetts General Hospital in Boston)
Statistics:

6. Endoscopy Risk factors
Large quantity of exams being performed and the invasiveness of the procedures puts patients at greater risk for errors and complications to occur.
Limited research on errors during the time out process during endoscopy procedures.
Errors and near misses in which no significant harm comes to patients causes staff to not report the incident.

7. Learning opportunities
Errors and near misses that occur with or without consequences can be an opportunity to learn and avoid a more serious future event.

8. In 2004 Joint Commission developed and mandated Universal Protocol during procedures. Their purpose was to create a National Patient Safety Goal that would eliminate wrong site surgeries.
History:

9. According to Joint Commission the Universal Protocol Timeout portion:
Requires an active communication among all members of the procedure team.
It should consistently be initiated by a designated member of the team.
It should be conducted in a fail-safe mode, so that the planned procedure is not started if a member of the team has concerns.
Requires the Universal Protocol time out to occur immediately prior to the procedure starting.

10. There is now a push for debriefing to occur after procedures to identify any safety concerns.
Many facilities are also broadening the patient safety practices and doing “expanded time out”, including making sure prophylactic pre medications were given and there is a designation of neutral zones (sharps section). 
New Changes

11. Example of Expanded timeout form

12. More changes
Safety Checklist are being incorporated during the pre- procedure evaluation or as part of timeout.

13. Example of safety checklist

14. Joint Commission did an evaluation of causes of wrong-site surgery errors and revealed 29 causes.
The causes were identified from several patient encounter areas, including the scheduling area, preop area, procedure area and with the organizational culture.

15. These 9 causes were seen in the procedure area and also related to the organizational culture.
With regards to issues with timeout, 9 out of the 29 causes for errors during timeout could be related to or are seen in endoscopy.

16. Joint Commission solutions to the 9 the causes of errors during timeout 
9 Causes of Errors During Timeout Related to the Procedure Room and the Organizational Culture.

17. 1) Inadequate patient information verification of primary documentation
Solution: Examine processes for inconsistencies and seek to understand the cause.

18. 2) Ineffective hand-off communication or briefing process.
Solution: Perform a pre-operative briefing in the procedure room with patient involvement, if possible, to verify patient identity, procedure site and side, along with other critical elements that need to be verified and addressed but are not part of the Time Out process.
Causes of Errors During Timeout

19. 3) Distractions and rushing during timeout.
Solution: • Work with procedure room team to develop a role- based Time Out process that works for your organization
►Perform a standardized Time Out process, which occurs after the prepping of the patient and includes the following elements:
*Every team member has an active role to play in the process.
*Address any concerns by the team before proceeding.
*Reduce noise and cease all other activity in operating room.

20. Positive Urine hCg case
Error in Picking Up a Positive HCG Lab

21. case one
A 40 yr old female patient was scheduled for a Colonoscopy procedure. On this day the endoscopy schedule was very heavy in volume and the procedures were running behind schedule. During the preop evaluation, the preop nurse felt she had to rush to get the patient ready in order to help speed up the process. At this facility, it is the protocol to complete a urine HCG on women of child bearing age to make sure that the female is not positive. The preop nurse did not look at the HCG lab value to notice that the lab was positive. In the report during the transition from the preop to procedure area, neither the preop nurse or procedure sedation nurse confirmed with each other the results of the lab. When the doctor reviewed the patient’s chart he also did not look at the lab value to see that the results were positive. The timeout was completed by the staff without them picking up the positive lab value. The patient was given Fentanyl and Versed by the sedation nurse and the procedure was completed. After the procedure was done the doctor realized that he did not check the lab value prior to procedure and looked at the results afterwards. This is when the mistake was realized.

22. Problems seen in the case
Inadequate verification of patient information by preop nurse to check to verify that the lab was completed.
Inadequate verification of patient information by the physician to verify that the lab was completed.
Inadequate hand off was performed by the preop nurse and the procedure sedation nurse.
Rushing by the staff because they were running behind.

23. 4) Time out process occurs before all staff are ready.
Solution: Empower all team members to participate in processes designed to reduce the risk of errors; everyone is expected to speak up.
Causes of Errors During Timeout

24. 5) Time out performed without full participation.
Solution: • Demonstrate leadership's commitment to implement standardized work processes.
Causes of Errors During Timeout

25. 6) Staff is passive or not empowered to speak up.
Solution: Share the data and allow the team to ask questions.
Causes of Errors During Timeout

26. Medication error case
Poor staff communication causes medication error

27. Case two
In an outpatient Endoscopy Center, a 54 yr old female patient was scheduled for an EGD. On this day, the procedure schedule was running behind and the schedule was heavy in volume. The doctor was under pressure because she was on call and after completing her procedures she had to round at the hospital. The doctor was receiving pages from the hospital while doing her procedures and felt pressured to answer the pages. The doctor did review the patient’s chart and saw the codeine allergy. The procedure sedation nurse also saw the codeine allergy. During the time out the sedation nurse verbally confirmed that the patient had a codeine allergy. However, while the timeout was being performed, the doctor received a page and became distracted because she wanted to answer the call. After the timeout was completed the doctor was so focused on wanting to answer the call she did not realized that she gave a verbal order for Fentanyl and Versed to be given then stepped aside to answer a call. The nurse did not confirm that the doctor was fully aware about the codeine allergy and she did not ask the doctor the rational why she chose to order Fentanyl to be given. When the procedure started both medications were given. After the procedure was completed the doctor was upset because she realized that she did not mean to order the Fentanyl and this was when the mistake was realized.

28. Problems with the case
The doctor was distracted and not fully participating in the timeout process.
Nurse was too passive and failed to speak up to confirm that the doctor was aware of the allergy.
Nurse was to passive to clarify with the doctor about the rational for why the medicine was order.
Staff was rushing to complete the procedures.

29. 7) Senior leadership is not actively engaged.
Solution: Hold all caregivers and staff accountable for their role in risk reduction; organization should define roles clearly.
Causes of Errors During Timeout

30. 8) Inconsistent organizational focus on patient safety.
Solution: Utilize an ongoing measurement tool for identifying inconsistencies in real time.
Causes of Errors During Timeout

31. 9) Marketplace competition and pressure to increase procedure volume leads to shortcuts and variation in practices.
Solution: Create an environment in which staff are expected to speak up when they have a patient safety concern.
Causes of Errors During Timeout

32. Drug screen error case
Failure to pick up drug screen results

33. Case three
In an outpatient Endoscopy Center a 28 yr old male patient was scheduled for a Colonoscopy procedure. On this day the schedule was heavy and the staff was rushing so as to not run behind. The patient was a known marijuana user, but, the doctor is suspicious that the patient maybe be using cocaine or other drugs. During the office consultation the patient was instructed to come earlier than his procedure time to do a drug screen, but, the patient failed to do so. The protocol at the endoscopy center is if the patient uses marijuana only a drug screen is not needed. However, if there is a suspicion or a confirmed previous use of cocaine use, then a urine drug screen is needed before the procedure. Preop nurses are suppose to check to see if drug screen orders are entered. During the preop evaluation the patient told the preop nurse that he only uses marijuana. The nurse took the patient’s word and did not check to see if there was a UDS ordered. During the transition between the preop and procedure area both the preop nurse and the sedation nurse failed to check if the UDS was ordered and done. The doctor also did not check to see if the UDS was completed. Timeout was completed. Fentanyl and Versed was given during the procedure. After the procedure the doctor remembered to check the lab and found out that it was never done.

34. Problems seen in the case
The preop nurse did inadequate verification of patient information to confirm that a UDS was ordered and completed.
Ineffective hand-off done by the preop nurse and sedation nurse which failed to check to see if a UDS was ordered.
Inadequate verification of patient information was done by the doctor to check lab prior to procedure to make sure that it was completed.
The staff was rushing.

35. Effects of the Culture of the Procedure Setting
The traditional culture of the procedure setting plays a major factor of the effectiveness of time out.
Three cultural barriers to effective time outs:
1) Team members embrace individual excellence instead of the team’s excellence and are used to working independently.
3) Team members are overwhelmed by staffing shortages.
4) Lack of respect amongst the team members impacts their interaction amongst each other.

36. Culture of the Procedure Setting Continued
It is important that each staff member recognizes the existence of these barriers and makes a personal evaluation of their role in how they impact the culture of the procedure area. Performing a self-evaluation helps them to determine if there are areas that they can make self-improvements to improve the culture of the procedure room. After doing so, each staff member should personally commit to improving the culture to a more positive and professional dynamic which is important to improving the quality of care that is given to our patients.

37. Best Practice for Timeout
In hospitals where time out occurs regularly and with meaning, the attending surgeon is the one who initiates the process and takes the lead. A reason is because the surgeon knows the full picture of the patient’s history. However, there is an active involvement of the Anesthesiologist, nursing staff or GI tech. The closer to the time that time out is completed prior to the procedure the less likely a mistake can be made. Using a combination of checklist and debriefings to maximize the amount of information communicated to team members before, during and after a procedure improves the quality of care.

38. Steps to Prevent Medication Errors During Timeout and Procedure
When a verbal order is given by a physician, always verbally repeat the order back to the physician to confirm that you heard the order correctly. If you have a question about an order always clarify your question with the physician prior to the administration of the medication and document physician rational. Be knowledgeable of drug information, interactions, patient allergies and your facility policy.

39. Take Away and Group Action Plan:
Start by making a personal evaluation of how you can improve the culture of Endoscopy through better communication and commitment to team excellence.
Do a personal evaluation of yourself to find areas that you can improve on the quality of care you give to your patients.
Make a commitment to voice concerns to the team that could impact the safety of your patients.
Always repeat back verbal medications orders to the physician to verify what you heard.

40. Take Away and Group Action Plan Continued:
If you have any concerns that arise during time out make sure to communicate your concerns to the doctor and allow for dialogue between the provider and you.
Document any rational expressed by the provider if there are variances.
Commit to making patient safety and delivery of quality of care your top priority.

41. We do not want to be among the statistics.
Remember
We do not want to be among the statistics.

42. References:

43. references
Matharoo, M., Thomas-Gibson, S. Haycock, M., Sendalis, N. (2013)Brithish Society of Gastroenterology. Implementation of an endoscopy safety checklist. Retrieved from Website:
Pellegrimi, C. (2017). Bulletin of the American College of Surgeons. Time out and their role in improving safety and quality in surgery. Retrieved from Website: their-role-in-improving-safety-and-quality-in-surgery/