Time Out Case studies
Case #1: The anesthesia care provider inserted the needle to perform an anesthesia block. The patient felt a twitch in their leg and stated that the twitch was on the left side and the surgery should be on the right side. The patient was correct.
variation from Time out: No site marking or Time Out had been performed for the block.
Case #2: Site mark for right stent placement placed on arm and was not visible after prepping and draping. Left stent placement performed.
variation from Time out: Site mark was not visualized during the Time Out.
Case #3: Surgeon consulted on patients in two different rooms. Surgeon performed knee aspiration on incorrect side thinking it was the other patient.
variation from Time out: Patient identity was not verified and Time Out was not performed.
Case #4: Patient consented to left knee arthroscopy. Right leg placed in holder and tourniquet placed. Surgical site had been marked but when initials were not seen on the right leg surgeon thought marked was removed by surgical prep.
variation from Time out: Site marked was not visualized during the Time Out.
Case #5: Patient consent for a right knee arthroscopy. All documents indicated right knee and right knee was site marked by surgeon. Surgeon and nurse put leg holder on left side of table and positioned left leg in holder. Left knee injected, prepped and draped. Time Out conducted and incision made to left knee. When nurse started documentation, she noted that the left knee was intended and informed the surgeon.
variation from Time out: Site mark was not visualized during the Time Out. All members of the team were not engaged in the Time Out process.
Case #6: Injection of anesthesia into the incorrect eye occurred because there was no site markings indicating the correct eye for operation. The anesthetic effect dissipated and operation on the correct eye was performed without complication
variation from Time out: No site marking or Time Out had been performed for the block.