TSU
Research in Nursing Practice
Abstract
Patient safety is important not only for patient but also for medical community, and this safety includes the reduction of medical and surgical errors. In the last few years, researchers have started showing great interest in the use of checklists before performing a surgery to reduce surgical errors. Usually, those checklists include the time out process, i.e. a kind of break or pause, before starting any surgical procedure. Those checklists may also include the information of patient, information of site or side, and information of procedure. Before starting any operation, operating staff communicate with each other. That communication may include the formal introduction and the information about the critical steps in the surgery. Different institutions adapt different checklists, but sometimes the operating staff may not comply with the points in the checklists. Therefore, we have to work on the weaknesses in published literature and improve the compliance of operating staff with the checklists including the time out process. This paper deals with some important aspects of the time out process. It also works on the future directions to help in further studies.
Key words: Time out, Surgery, Safety checklists
Introduction
Patient safety is one of the most important medical concerns before, during, and after a surgical procedure. Surgical errors such as wrong side or site, wrong procedure, and/or wrong person, though occur rarely, are considered as highly devastating events. In a study in the Netherlands, surgical errors were found in about 16% of cases (Haugen, Murugesh, Haaverstad, Eide, & Softeland, 2013). According to the National Patient Safety Agency, 129,419 cases of surgical errors occurred in England and Wales in the year 2007. In the U.S., about 28% of procedure related adverse events were reported in three different hospitals in 2011. Moreover, wrong-site procedure errors occured more frequently in surgical patients as compared to nonsurgical patients. Those errors resulted in different degrees of impairment or harm. Most frequently occurring problems associated with the surgical processes include hemorrhage, postoperative infections, hematoma, accidental puncture or laceration, and mechanical problems of noncardiac devices. These problems can lead to increased lengths of stay and higher hospital costs (McDowell & McComb, 2014). Research shows that checklists and time out process can help in reducing the surgery errors, thereby helping in confirming the correct site, correct patient, and correct procedure before a surgery.
Several human, material, and organizational factors are thought to have a role in causing surgical errors. Among the most important contributing factors in surgical errors are inadequate preoperative checks, communication breakdowns, simple human errors, and technical factors and imaging misidentifications (Haugen et al., 2013). In a study conducted by Haugen et al. (2013) performed in Haukeland University Hospital, it was found that anesthetic personnel have significantly higher scores on frequency of near-miss events as compared to room nurses and surgeons.
Adverse events in the case of surgical patients can be prevented in nearly half of the cases. Experts are of opinion that systematic use of a checklist before incision can be an effective preventive strategy. Moreover, improved level of communication between surgeons and anesthetists could further help in reducing such events. The Joint Commission (JC), an independent organization related to the certification and accreditation of healthcare organizations and programs in the U.S., has presented many risk prevention strategies to stop the surgical errors. The pause or time-out and active communication techniques are among those recommendations (Haugen et al., 2013). In many institutions, surgical time out is also used to improve quality of the procedure, and in some centers, it is also used for a formal briefing for all of the surgical team. Moreover, preprocedure verification and appropriate marking of the procedure site are also among the JC’s Universal Protocol. The site verification protocols may vary from one hospital to another (Lee, 2010).
Use of surgical checklists can help in reducing both mortality and morbidity. In a study in the Netherlands, it has been found that following the comprehensive Surgical Patient Safety System (SURPASS) of checklists, surgical errors could be prevented (Haugen et al., 2013). In order to improve the safety of patients, World Health Organization (WHO) developed a surgical safety checklist (Russ et al., 2015). These checklists allow that every member of surgical staff is accountable and identifiable, and knows the site, patient, and process of surgery (Lee, 2010).
In order to work on the efficacy of time out process in improving the safety of surgical procedures, we conducted a literature review on published studies dealing with the time out process. The reviews work on time out protocol from different dimensions as, for example, proper use of checklists having time out protocol, impact of time out in a neurosurgical department, and perceptions of surgical team members about time out process. PICO(T) question for the literature review was “How does conducting a "time-out" before beginning a surgical procedure is essential for preventing wrong-side, wrong-procedure or wrong-person surgery?”
P) For patients undergoing surgery
I) Taking preoperative time-out to increase patient safety
C) Standard Procedure
O) The effect on the rates of medical errors
Analysis
Researchers worked on the influence of time out practice on the safety attitude in a Tertiary Neurosurgical Department. They noted that University of California, Los Angeles (UCLA) Health System released a time out protocol in July 2011. The Health System considered various interventions to improve the observance of time out process and checklist completion for the time out process, and communication between healthcare personnel. McLaughlin and collaborators provided an online questionnaire to the members of the neurosurgical procedures in an operating room of the Ronald Reagan UCLA Medical Center. The members were asked to anonymously complete the survey to know about their perception about the time out process. Ninety three out of 128 members completed the survey, and nearly 99% of the participants of the study reported that time out process before incision helps in improving the patient safety. Nearly 98% of participants were of opinion that introductions of team members before a surgical procedure could improve team spirit during the surgery or operation. Research showed that 93.5% of the participants felt that communication of safety concerns throughout the procedure improved with the time out process. Presence of attending surgeon was found to be the most important thing during the time out process, and the review of potentially critical elements by the attending surgeon could improve the role of the team members. Researchers noted that although time out process helped in bringing the team together physically, but it would not help in reinforcing teamwork. Therefore, further work is required in leadership training as well as teamwork training (McLaughlin, Winograd, Chung, Van de Wiele, & Martin, 2014). This study had a limitation of getting individual attitude about time out process. Moreover, the online survey, which can give different response as compared to face-to-face survey, was not validated that can impact the authenticity of the study.
In a survey on the perceptions of the team members of surgery about near misses, and their attitudes towards the time out process, researchers noted that medical errors were of special concern in the healthcare industry. Those errors might include surgical errors including wrong site, wrong patient, and wrong procedure, which could be devastating. They were trying to find reasons behind incorrect surgery, and in this regard, they surveyed the surgical team members. They hypothesized that attitudes of surgical team members towards time out protocols and their perceptions of near-miss experiences can be of significant differences. Researchers conducted a cross-sectional study on 427 participants including anesthetists, surgeons, nurse anesthetists, and nurses. A questionnaire was provided to the participants of the study. The questionnaire was about the experience of team members about near misses; their strategies to verify the correct site, patient, and procedure, and their acceptance of the use of the protocol. Nearly 38% of the participants showed uncertainty of the identity of patient, 81% of the participants showed uncertainty about the surgical site, and 60% of the participants showed that they were near to perform almost wrong procedure. This showed that most of the participants nearly missed the correct patient, site, or procedure. Therefore, it is vital to use the checklist before a surgery. Almost 91% of the participants of the study supported the use of time out process for correct site, patient, and procedure (Haugen et al., 2013). This study could result in biased conclusions as it was done on the basis of memory of the participants. Therefore, further study can be conducted to reduce the memory bias and increase the validity of the research.
In another research, WHO Surgical Safety Checklist and its variation between hospitals were studied. Study showed that full use of safety checklists could help in improving the outcomes as well as team effectiveness in a surgical procedure. However, standardized and reliable tools are required for checking the quality of the use of safety checklists. Researchers conducted a multicenter prospective study, and used an observational instrument referred to as “Checklist Usability Tool” (CUT). They tried to determine the characteristics related to the use of Surgical Safety Checklist in five English hospitals, and conducted 565 observations for the time out process and 309 observations for the sign out process. Nearly two-thirds of the items were checked by the participants. They also reported that over 40% of cases lack team members, and in more than 70% of cases, team members failed to focus on the checklist or pause for communication. Over 39% of cases lack completion of sign out process. Researchers also found that huge variation was found between hospitals in the use of checklists. However, there were no significant variations in the use of checklists between surgical specialties and emergency procedures. It was also found that the Surgical Safety Checklist improved, when surgeons led all the team members, and there was an appropriate time out process (Russ et al., 2015). This study was done in some specialties such as general surgery, orthopaedics, and urology, and cannot be generalized to the whole population. Another point is that results of the study could be influenced by the presence of observers, but researchers tried to deal with this point by using the observer repeatedly for procedures. They also used more statistical analysis, therefore, it can assumed that more validated results were obtained.
In a study published in 2010, Lee worked on the efficacy of extended surgical time out in pediatric surgery. Lee asked the surgical team members to implement and used an extended surgical time out. The members of the team confirm the identity of the patients, anesthetic and technical details, available and administered medications, and the requirement of blood products as well as special equipments. He found that the extended surgical time out helped in improving and confidence of the operation room staff due to improved communication. He also noted that special consideration was given to antibiotics and equipments. Extended surgical time out process not only improved communication, but also did not disturb the workflow. However, extended time out was not able to eliminate the surgical error completely (Lee, 2010). In the study, Lee performed the research on pediatric patients and used Student’s t-test in statistical analysis. He also added a method referred to as extended surgical time out procedure along with the survey to validate the results of the study.
In 2015, researchers studied the efficacy of aviation-style teamwork training to improve the performance of the operating theatre team as well as the clinical outcomes of the procedure. They studied three operating theatres in UK, and studied 72 operations. The teamwork-training course was provided to the staff. Researchers evaluated the whole team for their non-technical skills such as leadership, management, cooperation, problem solving, decision-making, and situational awareness, utilizing Oxford NOTECHS II, and checked their compliance with the WHO checklist. They were also assessed for their attempt of time out and sign out checks. Time out procedures significantly improved after training. Moreover, teamwork training can also help in improving non-technical skills (Morgan et al., 2015). This study was actually a comparison of control group with active group, i.e. it is a kind of empirical research in checking the efficacy of time out process. Therefore, it can be considered as one of the most valid methods of estimating the effectiveness of the use of surgical checklists.
In a systematic review, investigators worked on the published literature considering the use of Safety Checklists. They noted that almost 50% of the surgical complications could be prevented. Studies showed that preprocedural surgical safety checklist could help in dealing with surgical complication rates. Most of those studies are published after 2011. Therefore, it can be deduced that healthcare experts have started showing more interest in safety checklists in the last 5 to 6 years. Researchers noted that improvements could be made with team discussions and overall communication. Moreover, team members have positive responses towards the efficacy of the safety checklists. They also noted that education could help in enhancing the compliance of the operating room staff for the checklist (McDowell & McComb, 2014).
Consistencies and/or Contradictions
The results of almost all the studies are consistent, and showed that the time out process could help in improving the surgical errors. Moreover, the team members are of opinion that time out process has to be done before performing a surgical procedure. Studies also show that training of operating staff could improve their utilization of the checklists. In a recent review published in the journal Frontier in Pediatrics, Corbally (2014) also noted that time out or surgical pause including parental involvement along with team-based responsibilities and team briefings could help in reducing surgical errors.
Conclusions and Recommendations
Time out process is an essential process in which operating staff take a break, collaborate with each, and communicate the appropriate steps in the surgery. This can help in reducing surgical errors including wrong site, wrong person, and wrong procedure. Various checklists have been developed such as WHO Surgical Safety Checklist to reduce the surgical errors and to include the time out process and sign out process (Russ et al., 2015). However, different healthcare institutions may use different checklists in different ways; therefore, it becomes essential to adapt some standard protocols to be followed in every institution.
Although there are no contradictions in the studies, but there are some limitations in the studies. Usually, the studies for the time out process are surveys or questionnaires sent out by leaders of the surgical team, thereby representing the aggregated attitudes of the operating staff rather than individual attitude. In some cases, the survey tools have not been validated (McLaughlin et al., 2014) showing that the results could be different, if the survey tool is validated.
Another point of significance is that studies could give different results in different specialties and scarce data is available on the differences in observations from different departments or specialties. Moreover, observations could also vary from one nation or group of people to other nation or group of people, and there is no data on the difference in results in different nations (Russ et al., 2015).One of the most important points to consider is that there must be international collaborative studies in time out process and filling the checklists. Those studies could help in generalizing the research and improving the surgical procedures.
Compliance of surgical staff in the completion of checklists and briefings also needs further studies. Therefore, further empirical research with longitudinal study design can be done in finding and improving the compliance of surgical staff. Those longitudinal studies can help in learning more not only about the cause and effect relationships, but also give more concise and better results. Those studies could also help in reducing biases as, for example, in filling out a survey, surgical team members rely on their memories, therefore, filling the survey immediately before or after the procedure could reduce bias by giving the right answer to researchers.
References
Corbally, M. T. (2014). Can we improve patient safety? Frontiers in Pediatrics, 2, 98. doi: 10.3389/fped.2014.00098
Haugen, A. S., Murugesh, S., Haaverstad, R., Eide, G. E., & Softeland, E. (2013). A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols. BMC Surgery, 13, 46. doi: 10.1186/1471-2482-13-46
Lee, S. L. (2010). The extended surgical time-out: does it improve quality and prevent wrong-site surgery? The Permanente Journal, 14(1), 19-23.
McDowell, D. S., & McComb, S. A. (2014). Safety checklist briefings: a systematic review of the literature. AORN Journal, 99(1), 125-137 e113. doi: 10.1016/j.aorn.2013.11.015
McLaughlin, N., Winograd, D., Chung, H. R., Van de Wiele, B., & Martin, N. A. (2014). Impact of the time-out process on safety attitude in a tertiary neurosurgical department. World Neurosurg, 82(5), 567-574. doi: 10.1016/j.wneu.2013.07.074
Morgan, L., Hadi, M., Pickering, S., Robertson, E., Griffin, D., Collins, G., . . . New, S. (2015). The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: a controlled interrupted time series study. BMJ Open, 5(4), e006216. doi: 10.1136/bmjopen-2014-006216
Russ, S., Rout, S., Caris, J., Mansell, J., Davies, R., Mayer, E., . . . Sevdalis, N. (2015). Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. Journal of the American College of Surgeons, 220(1), 1-11 e14. doi: 10.1016/j.jamcollsurg.2014.09.021
