Derek Atkinson:Welcome to The Patient Safety Huddle, presented by the VA National Center for Patient Safety. I'm your host, Derek Atkinson, Public Affairs Officer. June 14th is widely recognized as Flag Day in the United States, but there's also a lesser known observance on the 14th called National Time Out Day. Joining me today to discuss National Time Out Day is Dr. Douglas Paull, NCPS Senior Medical Officer and Deputy [00:00:30] Director. Hello, Dr. Paull. How are you?
Dr. Paull:I'm doing well, thanks Derek.
Derek Atkinson:Thank you for joining us today on The Patient Safety Huddle.
Dr. Paull:My pleasure.
Derek Atkinson:Before we get started, could you tell our listeners a little about yourself?
Dr. Paull:Sure. I guess on National Time Out Day it's important to know that first and foremost I'm a surgeon. I'm board certified in general surgery and in cardiothoracic surgery. While most of my career has been spent in operating rooms, I also share your and your audience's passion for patient safety. I went back to school [00:01:00] and received a Master's degree in Patient Safety and I've been at the VA National Center for Patient Safety in Ann Arbor for the last 10 years serially as co-director of team training, then director of patient safety curriculum, and now as Deputy Director of the National Center for Patient Safety. During all that time I've been part of a leadership team that reviews and writes VA policy and develops training to support that policy concerning time outs.
Derek Atkinson:Thank you for that, Dr. Paull. Can you tell me a little bit about Time Out Day?
Dr. Paull:[00:01:30] Sure. National Time Out Day, it's an annual awareness campaign. It's sponsored by AORN, which is the Association of periOperative Registered Nurses, and the Joint Commission, and it's designed to increase awareness of safe practices, specifically the time out, that lead to best outcomes for patients undergoing either surgery or invasive procedures.
Derek Atkinson:What is a time out?
Dr. Paull:One way to describe it, Derek, it's like a pause; a pause for safety that occurs [00:02:00] right before each and every operation or invasive procedure. The time out is quite standardized. By that I mean if you were to visit an operation room, and I mean whether in the VA or outside the VA in Montana, and then go to a different operating room in Florida, you'd still recognize the time out process very clearly. It involves every member of the team; the anesthesia attending or nurse anesthetist, the scrub nurse or circulating nurse, the techs involved, and surgeons. [00:02:30] Sometimes that team is relatively small, say for hernia surgery, but sometimes that team is quite large, such as open heart surgery where even the perfusionist, the people running the heart-lung machine, would be intimately involved in the time out process.
Team members communicate. They confirm that the patient's identity, the correct site of surgery, and the exact procedure to be performed. Those things can get kind of confused in a busy operating area full of distractions. [00:03:00] The time out is completed and then documented in the chart. The time out is really part of an overall system that's designed to ensure correct surgery and invasive procedures. That's system is called the Universal Protocol, and it's been in existence from the Joint Commissions since July of 2004. The Universal Protocol includes a pre-procedure verification process that usually occurs in the holding area; that is, the area even outside the operating room before the patient goes in. During that period of time [00:03:30] the physician will mark the procedure site, and then within the operating room, after the patient is prepped and draped, that's when the time out occurs.
Derek Atkinson:Does conducting a time out improve patient safety?
Dr. Paull:Well, Derek, the short answer is yes, but in this day and age medicine often demands multiple randomized controlled trials showing positive outcomes before a drug or a process or some change is accepted, and even after that it often takes years, if not [00:04:00] decades, to be fully accepted. That kind of proof is hard to do with some patient safety problems. Some of these patient safety problems are quite rare, like wrong site surgery. These events may only occur once in tens of thousands of cases, making it very difficult to compare an intervention group to a control group of patients, and then achieve any kind of statistical significance between the two groups. In fact, it would probably take an infinite amount of time and cases [00:04:30] to really study that completely. That being said, there is a randomized control trial, an international study, that demonstrated fewer wrong site procedures when a time out was employed. There have been many other studies short of randomized control trials that have given evidence and wisdom of the time out.
One study that I can recall was from the Pennsylvania Patient Safety Reporting System where they looked at close calls versus actual wrong site events. The close calls were more likely [00:05:00] to have completed the time out, marked the site, and so on. Again, that's pretty good proof that time outs work. At this point, I think it might be unethical to expose one group of patients to time outs and another group to no time outs. Time outs have been embraced the world over and, in fact, combat surgical teams even do time outs.
Derek Atkinson:The Department of Defense is also utilizing this practice?
Dr. Paull:Absolutely.
Derek Atkinson:Wow, fantastic. Are time outs only used [00:05:30] in the OR by surgeons like yourself?
Dr. Paull:No. Since July of 2004 the Joint Commission's actually mandated the use of time out prior to all invasive procedures, not just those in the operating room, but even those invasive procedures occurring outside the operating room. Certainly every surgeon and every surgical team must utilize a time out, but for that matter any physician who performs an invasive procedure. For example, a colonoscopy in a clinic must also use a time out prior to every single procedure. [00:06:00] You know, wrong site surgery may be rare, but when it occurs it's devastating for patients, their families, the team involved, and the entire healthcare organization. Veterans lose trust in the organization. Wrong site surgery is almost always preventable, and with rare exception the time out will prevent wrong site procedures. Surgeons who do not conduct time outs can be fined, and they can even lose their license if they experience a wrong site procedure.
Derek Atkinson:[00:06:30] How does VA compare to the private sector when it comes to incorrect surgery?
Dr. Paull:That certainly is an important question, especially of interest to our VA audience members. Bottom line, we do very very well, but direct comparisons are difficult. Let me explain. The VA has a broad definition of wrong site procedures. It includes wrong side, wrong site; for example, the wrong finger on the correct hand, wrong implant, wrong level; such as a wrong spine level, [00:07:00] wrong procedure, and wrong patient. Other states, and for that matter other healthcare organizations, do not include wrong implant or wrong level spine in some of their registries. Wrong implant and wrong level procedures are among the most common wrong site procedures, so now you begin to see the problem. We're comparing apples to oranges, and the press, and therefore the public, oftentimes don't really get the complete picture. They don't have the complete information. [00:07:30] Even with these disadvantages the VA does great.
Over the last year, VA did in excess of 411,000 procedures of all kinds, and had 14 events, for a rate of about 1:29,000. That is what quality gurus call approaching Six Sigma, or near perfection, and this is not an accident.
Derek Atkinson:That's really good to hear if I need to have surgery at some point I'll be receiving high quality and safe care.
Dr. Paull:The Veterans [00:08:00] deserve that and much more.
Derek Atkinson:For those clinicians out there utilizing time outs, how can they make those time outs more productive?
Dr. Paull:That's a great question, and I would say make it a team event. Surgeons aren't perfect. They make mistakes. It's likely that other team members are going to discover those mistakes and can disclose those errors or problems. If they speak up, harm can be avoided to the patient. Everyone should participate in a time [00:08:30] out, and especially newcomers on the team. It really is all about the culture of patient safety and leadership engagement. If the surgeon encourages everyone to participate in the time out and to speak up, it creates an atmosphere that promotes patient safety.
Second, I would encourage everyone to use a checklist. No need to remember everything, the checklist makes sure we don't forget any items in the Universal Protocol and in the time out. Finally, [00:09:00] when things go wrong, or even when there's a close call, report these things to the patient safety manager. We're reporting culture and we learn from our mistakes.
Derek Atkinson:National Time Out Day on June 14. We had Dr. Douglas Paull from the VA National Center for Patient Safety joining us today. Dr. Paull, thank you so much.
Dr. Paull:You're welcome.
Derek Atkinson:For more information about the VA National Center for Patient Safety please go to