TIME OUT – AVOIDING WRONG SITE SURGERY – AN AUDIT OF SIX MONTHS EXPERIENCE

Abstract

The purpose of this paper is to review the first six months experience of using the ‘Time Out’ procedure to avoid wrong site/side surgery and to evaluate the usefulness of this procedure in the routine preoperative check.

Over a period of 18 months all elective surgical hospitals in Christchurch (both private and public) have coordinated to develop a pre-operative ‘Time Out’ check list to ensure that the correct surgical procedure is performed on the correct site. This procedure involves a final check of patient details, including surgical procedure and site, immediately prior to surgical preparation of the operative site.

All forms during this six month period were prospectively collected and evaluated, specifically looking for system errors, which could proceed to wrong site surgery.

There were a total of 10,330 procedures performed during this period within the three hospitals of which 9,098 (87.2%) completed time out forms were returned.

There were no wrong side or wrong site surgeries performed during this six month period. However, there were three ‘near miss’ situations which were captured by the time out procedure.

Analysis of the time out forms also revealed numerous consent issues, incorrect documentation and systems errors which could potentially have lead to serious errors in management and which will be discussed in detail.

During this period there were 109 objections (1.2%) to the time out procedure.

The time out procedure has been shown to be a useful tool for avoiding wrong site/side surgery and has gained acceptance amongst both medical and nursing staff as being a valuable check prior to surgery. It has accentuated the collective team responsibility for determining the correct site and side of surgery and as such is recommended for use in all centres to eliminate system errors resulting in incorrect site/side surgery.