Time-out Process Research Articles

Implementation of a Standardized Discharge Time-out Process to Reduce Prescribing Errors at Discharge

Background To reduce prescribing errors occurring on discharge from the hospital, a standardized discharge time-out process was implemented on a general medicine service at Wake Forest Baptist Medical Center. In the time-out process, the multidisciplinary care team reviewed the patient's medical records together to determine the optimal discharge medication regimen. This regimen was recorded on a time-out form and then was used to develop the patient's discharge documents. Objective To evaluate the impact of a standardized discharge time-out process on prescribing errors that occur as patients are discharged from a general medicine service. Methods The medical records of all patients discharged from a general medicine service during 60-day periods before (“pre-group”) and after (“post-group”) implementation of a standardized discharge time-out process were retrospectively reviewed by an internal medicine physician to determine the presence of discharge prescribing errors. Results There were 142 and 124 evaluable patients in the pre- and post-groups, respectively. Compliance with the time-out process was 93% in the post-group. At least 1 prescribing error was detected in 49 (34.5%) of the discharges in the pre-group and 17 (13%) of the discharges in the post-group ( P < .0001). All of the errors noted in the post-group occurred in discharges in which a clinical pharmacist was not involved. Conclusions A multidisciplinary, standardized discharge time-out process was associated with a dramatic reduction in prescribing errors when patients were discharged from a general medicine service. The time-out process is one strategy to improve patient safety at hospital discharge.

Observations of Pre-operative Teamwork and Communication During the Implementation of a City-Wide Surgical Safety Checklist

BACKGROUND: Use of the World Health Organization's (WHO) perioperative safety checklist has been shown in prior studies to reduce morbidity and mortality. In 2009, the Medical Society of Sedgwick County, Kansas, developed a modified version of the WHO checklist for city-wide implementation. This study evaluated how the checklist was used at a Wichita hospital. METHODS: An observational tool was developed to evaluate time-outs at the beginning of surgical procedures. A convenience sample of cases was evaluated across surgical specialties and procedures. Observations included: 1) when the time-out was done, 2) who led the time-out, 3) which items on the checklist were addressed, 4) how much time was spent, and 5) whether problems were identified or adverse events prevented. RESULTS: Data were collected from 121 observations. Only one of the surgical teams was observed to refer directly to the checklist posted in the OR to conduct their time out. The time-out was done before induction (3%), drape (19%), incision (77%), and after incision (1%). The process was led by the circulating nurse (92%), surgeon (7%), and circulating nurse and surgeon together (1%). The percent of completed checklist items was: patient identity (96%), procedure (96%), antibiotics (87%), site (80%), allergies (75%), position (70%), equipment (60%), DVT prevention (50%), images (40%), surgeon concerns (36%), and anesthesia provider concerns (34%). On average, seven (SD = 2.5) of 11 items on the checklist were addressed. Time spent ranged from less than one minute to five minutes; 78% took one minute or less. Problems were identified in 7% of cases. In one case, a wrong site surgery was prevented. CONCLUSIONS: Despite the intention to implement a city-wide surgical safety checklist, the checklist rarely was used in its entirety to conduct the observed time-outs in the subject hospital. Although the checklist was under-utilized, safety benefits were observed from the time-out process. These would likely be enhanced and extended by consistent use of a checklist.

University of California, Los Angeles, surgical time-out process: evolution, challenges, and future perspective

Since the development of the WHO Safe Surgery Saves Lives initiative and Surgical Safety Checklist, numerous hospitals across the globe have adopted the use of a surgical checklist. The UCLA Health System developed its first extended Surgical Safety Checklist in 2008. Authors of the present paper describe how the time-out checklist used before skin incision was implemented and how it progressed to its current form. Compliance with the most recent version of the checklist has been closely monitored via documentation and observance audits. In addition, the surgical team's appreciation of the current time-out has been assessed. Cultural, practice, and human resource challenges are discussed, as are potential future avenues for innovations in the emerging field of the surgical checklist in neurosurgery.

Improving Team Performance During the Preprocedure Time-Out in Pediatric Interventional Radiology

The preprocedure time-out is a high-profile safety measure, and compliance is coming under increasing scrutiny. A checklist-based scoring system was developed to rigorously assess compliance, and a system of video monitoring and feedback was used to track performance and improve the time-out process in pediatric interventional radiology. A time-out "script" containing a series of observable behaviors to be performed collectively by the physician, nurse, and technologist before each interventional procedure was used to create a checklist. A procedure room equipped with an audio/video recording system allowed capture of time-outs for later review. The reviewer scored one or two time-outs each week, and the results were posted to provide feedback. The process of continual feedback and modification led to substantial improvements in time-out performance during a three-year period. Analysis of subscores revealed common failure modes that were subsequently addressed. The scoring checklist was also modified after analysis suggested redundant or unnecessary items. Gains were noted in the efficiency of the time-out protocol, which took more than 1 minute in the initial stages but soon shortened to 30-45 seconds as the team gained experience. Assessment of scoring consistency across three independent observers revealed 93% interobserver agreement and 95% intraobserver agreement. Clarification of the scoring criteria led to improved consistency (97% and 98% inter- and intraobserver agreement, respectively). The combination of a time-out checklist, recorded procedures, review, and feedback produced not only improvements in time-out performance but also improvements in the scoring system and time-out process.

Getting surgery right.

We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part). We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006. Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%). Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92. Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing "wrong" surgery. Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons' best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.

The key technologies in multi-call processing of the VolP Gateway

Bacause Gateway serves many users, there are some related problems to be solved, such as the allocation and management of multiple calls, the synchronization of multiple threads, the state transference and time-out processing. To solve these problems, key technologies in our implementation will be proposed, which are important to the stability and efficiency of the Gateway. At last, the test of our Gateway is shown and analyzed.