SDS Accreditation Update: Time-out is the key to correct surgical site ID

In addition to posting signs in the operating room to remind staff to take a time-out just prior to the first incision to verify the surgical site, there are other activities you should perform on an ongoing basis to make sure staff follow your time-out policy, says Colleen J. Trask, RN, CNOR, director of perioperative services at Greenville (SC) Hospital System.

"The Joint Commission surveyors who were here for our March 2003 survey were very pleased with our efforts to meet National Patient Safety Goals, including our emphasis on time-out," Trask explains.

Her organization makes sure time-outs are performed consistently by using a variety of monitoring techniques, says Trask.

"We do review operating room records to monitor documentation of time-out, but the most important activity is the constant presence of supervisors and managers," she says.

"All of the supervisors are in and out of the operating rooms, frequently helping with preparation of the patient, so they are often present to witness the time-out," Trask adds.

Because managers and supervisors often provide relief for circulators to take lunch breaks, they also get a chance to lead by example, she says.

This "practicing what they preach" is effective for reinforcing staff education, she points out.

Physicians also are familiar with and supportive of the time-out philosophy, Trask explains.

"We have a perioperative committee that includes physicians from all sections of the medical staff associated with surgery, and we introduced the policy to them for them to take back to their departments," she says.

"We made sure we explained that the idea behind time-out is to keep our patients safe, which also means that we are protecting not just the patients, but the hospital and the surgeons as well," Trask adds.