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Get in Rhythm. Stay in Rhythm.™ View Replays from Atrial Fibrillation Patient Conference Aug 4-6, 2017, in Dallas, TX
Get in Rhythm. Stay in Rhythm.™ View Replays from Atrial Fibrillation Patient Conference Aug 4-6, 2017, in Dallas, TX

Speak Up for Your Safety Before Your Procedure

The Inside of a Time Out: A Case from the Agency for Healthcare Research and Quality

August 22, 2008 6:12 AM CT

If you are considering a procedure of any kind, you'll want to read The Inside of a Time Out, a fascinating case and commentary at Medscape about the importance of time outs in the operating room. This comes from the Agency for Healthcare Research and Quality (AHRQ).

In an effort to eliminate wrong site surgeries, the Joint Commission made time outs mandatory and hospitals are obliged to ensure that they are performed. Some hospitals have broadened time outs to include patient safety practices.

The case presented and discussed dealt with a patient having elective surgery who had an allergy to intravenous contrast dye. The allergy was noted during his preop visit with an anesthesiologist. During the pre-surgery time out, a nurse raised the concern, but the anesthesia resident was intimidated and allowed the surgery to proceed.

Fortunately, the patient was fine, but this case raises the concern that patient safety may fall victim to cultural or other issues.

One of the take-home points is that "Every facility needs to examine the pervasiveness of traditional cultural barriers that prevent some members of the team from speaking up, since this will significantly hamper any patient safety effort, especially the performance of a quality time out."

If you are having a procedure of any kind and have a concern, speak up early, loudly and often to every member of the team, and have your patient advocate do so as well. You can't be too careful, and the price of not doing so could be great.

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Last Modified August 22, 2008

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