Pause for thought - Surgical Time Out: Before or after Painting & Draping. A Quality Improvement Project.

Background: In recent years surgical errors have received increasing attention and so called ‘never events’ include wrong site/side/patient surgery. Both the Joint Commission and the World Health Organisation have sought to reduce the risk of these events occurring with the introduction of the Universal Protocol (Joint Commission International, 2004) and Guidelines for Safe Surgery: safe surgery saves lives (World Health Organisation, 2007). Despite these initiatives, surgical never events continue to occur. Context: This Organisational Development (OD) project aimed to align the organisations ‘Time Out’ process with the WHO directive that ‘Time Out’ occurs immediately prior to knife to skin. Using action research based on the Senior & Swales (2010) OD model for change, the current situation was diagnosed through audit, informal interviews, internal data review, assessment of current literature and survey data of the practices in other private hospitals in Ireland. The future state which is envisioned is to never have a surgical ‘never event’ in our organisation. Commitment to our vision was gained through management sponsorship, stakeholder analysis, support of champions, presentations and discussions with surgeons and staff. Developing an action plan was the remit of the implementation team who agreed the PDSA methodology. The change was implemented through pilot of surgical procedures and was audited throughout the process. Evaluation found that there was a 6% decrease in the ability to confirm the patient identity and a 42% reduction in the visibility of the site mark. While overall the objectives of the project were achieved, feedback from surgeons and staff was that the proposed change increased the likelihood of ‘wrong site surgery’ and should not be implemented. However, opportunities for improvement in regard to scheduling of surgeries, confirmation of imaging and improved site marking practices were identified. Finally the writer concludes that further study is required on ‘Time Out’ and the apparent disconnect between theory and practice.