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2013 YP Award Essay 3
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2013 Winner - Essay 3

The Doctors Company Foundation Young Physicians Patient Safety Award

 

As I stood in the operating room getting ready for the case to start, I looked around at the many people who were contributing to our patient’s surgery. The circulating nurses were bringing special equipment and sutures into the room, the scrub nurse was completing her instrument count, the anesthesiologist was monitoring our recently intubated patient, and I was helping the resident drape the patient.

 

The attending surgeon walked in, gowned up, and stood across from the resident.

 

“Scalpel,” the attending said, with his palm outstretched to the scrub nurse.

 

The circulating nurse turned her head from the computer screen and said, “Sir, can we do a time-out now?”

 

“Uh, yah, whatever. Mr. X is a 49-year-old man here for an open cholecystectomy. Scalpel?”

 

The scrub nurse handed him the scalpel and we proceeded with the case.

 

Technically, we had completed a time-out, but the quality of this time-out was extremely poor. Did our patient’s common name match his medical record number? Did we start antibiotics? Did our patient have any specific allergies? These were all important questions that could have significant, preventable consequences if not considered. And what if this were my dad on the operating table – would I have spoken up? And if I did, would it matter? All these thoughts rushed into my mind as we made our first incision.

 

In the coming weeks, I shuddered as I observed countless more time-out procedures that were performed incompletely, hastily, or not at all. I know most people were familiar with the fact that a standardized checklist has been shown to decrease patient morbidity, mortality, and complication rates worldwide,(1) yet everyone seemed to think that a full time-out procedure would be a waste of time. Even worse, the atmosphere in the OR did not seem to welcome input from the various team members that were so essential to our patient’s care. As a medical student helping establish our university’s Institute for Healthcare Improvement chapter, I became fascinated by this significant problem in patient safety and brainstormed how I and other students could get involved in reducing the number of preventable surgical errors at our institution.

 

To start, a classmate and I met with surgeons, nurses, perioperative staff, the chief quality officer, and the chief hospital epidemiologist at our medical center to see if an institution-wide implementation of a standardized checklist would be both beneficial and feasible. We soon realized that the immediate problem of our time-out process was not the content of the time-out itself, but rather compliance with performing the existing items in the first place. Studies have shown that surgical team willingness to comply with the time-out procedure is influenced by a complex interplay of organizational, departmental, and individual factors, such as level of education and training of safety practices, degree of simplicity and standardization of time-out, impact of the time-out on the efficiency of cases, and perceived value of the time-out among individuals of the surgical team.(2,3) With this in mind, we hypothesized that directly addressing these issues, through implementation of an interactive electronic checklist system, could increase surgical team compliance with the time-out procedure and improve communication in the OR, arguably two of the most important components in decreasing preventable surgical errors.

 

As project leader, I assembled a team of medical students and faculty members to help me with this study. After obtaining IRB approval, my teammates and I embarked on a 12-month prospective, pre- and post-implementation study in which we observed time-out procedures of 240 operations. Pre-intervention observations indicated that surgical staff verbally communicated the core (required) elements of the time-out procedure 49.7% ± 12.9% of the time. After implementation of the electronic checklist system, direct observation of 80 surgical cases at 1 month and 9 months indicated that surgical staff verbally communicated the core elements of the time-out procedure 81.6% ± 11.4% and 85.8% ± 6.8% of the time, respectively, resulting in a statistically significant (p<0.0001) sustained increase in time-out procedural compliance.(4)

 

These results were staggering, especially considering that the contents of the time-out checklist remained unchanged; only the method of facilitating the time-out process was altered. To me, this was an inspiring example of how a relatively simple system/process change could ultimately impact patient safety and outcomes. The electronic checklist system facilitated standardization of the time out process by displaying the required components on the whiteboard screen and requiring user interaction and documentation at each step in the process. This active process contrasts pre-implementation methods in which surgical team staff would attempt to recall the time-out elements from memory, often leaving out information in a setting where comprehensiveness is imperative. This intervention offered reduced reliance on human memory, greater compliance with a standardized process, improved information access, and immediate visual feedback. 

 

Now, two years after I witnessed the poor-quality time-out before Mr. X’s cholecystectomy, the time-out process at my institution has completely changed. It is more comprehensive, it involves participation and attention from everyone in the multidisciplinary OR team, and it grants teams an opportunity to voice special considerations. Attending the NPSF Patient Safety Congress would enable me to meet leaders in this field and learn about initiatives tried at other hospitals. No matter what specialty I ultimately pursue, I want to acquire the knowledge, skills, and experience to positively impact patient care through quality improvement. I am encouraged by the increased emphasis on quality improvement and patient safety nationwide and am optimistic about how my peers and I will integrate this into our medical training. Change sticks when there is there is a conscious effort to show people how new approaches, behaviors, and attitudes can improve outcomes, and I hope to champion this effort throughout my career. This scholarship and opportunity would help me immensely as I work toward that goal. ¨

 

  1. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–499.
  2. Gillespie BM, Chaboyer W, Wallis M, et al. Why isn’t “time out” being implemented? An exploratory study. Qual Saf Health Care 2010; 19:103–106.
  3. Wilson I, Walker A. Theatre checklists and patient safety. Anaesthesia 2008; 63:921–923.
  4. Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery. 2012;151(5):660–666.

*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.

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