Photo by Russell Stitzlein
About a month ago, I walked into the OR and found out that my patient had quite the sense of humor. In addition to the stamp which one of the surgeons applies to indicate the correct side, our patient had gotten ahold of a skin marking pen and wrote “THIS KNEE” over his right knee on which we were about to perform an arthroscopically assisted anterior cruciate ligament (ACL) reconstruction. We had a good chuckle over it and then proceeded in our usual fashion without complication.
Then, last week after I’d finished positioning and prepping our patient, a case – left tibial tubercle open reduction with internal fixation (ORIF)– and my attending came in the room, nodded in approval at the progress, and asked, “what’s next?”
I replied, “Time Out.”
My attending responded, “Go ahead.”
Admittedly, I was caught off guard. I’ve been in the operating room for several hundred cases, each of which is preceded with a surgical “time out,” but I’d never been the one to actually run the time out. Usually I find myself half-listening, making sure that the correct procedure and laterality is announced while finishing with the set up in order to begin the case as quickly as possible. This time would be different. This time I would have to recite all the components of the time out as well as confirm the accuracy of each step. Luckily, each OR is equipped with an oversized print out of the surgical time out steps that I could reference so that I didn’t fail miserably in my first time out.
Having the opportunity to run a time out gave me a new perspective on the process. Previously, I saw it as a redundant pause in the action to again ensure we were operating on the correct side. Presumably, prior to the time out, the surgical team has confirmed with the patient the correct procedure and laterality and then marked the correct side. Additionally, the pre-op nursing staff, the OR staff and the anesthesia team have all confirmed this prior to the patient ever being placed under anesthesia. So, it’s easy to understand how the surgical time out can be seen as just a formality that need not be taken too seriously. But after having the opportunity to run a time out and think critically about each of the items, it became clear that the surgical time out is much more than just re-confirming the laterality. It’s a final opportunity to make sure that everyone is on the same page and prepared for the case and that all necessary items are available.
The surgical time out is our opportunity to avoid significant delays in the case as well as ensure preventable errors are prevented. Among the many ways the time out can prevent delays are ensuring the appropriate antibiotics have been given and have been given in the sixty minutes prior to making incision (evidence-based timing of antibiotic administration to reduce the risk of surgical site infections), ensuring fluoroscopy (both the machinery and technician) is available if intraoperative imaging is required, and ensuring all necessary instrumentation is available. Having appropriate instrumentation is often of paramount importance in orthopaedic surgery. We generally have several trays of instruments open for each case and often need several more to be readily available as a case unfolds. If the appropriate instruments are not available it can mean a significant delay (while the patient remains asleep) or limit the surgeon’s ability to produce the optimal outcome.
At heart, the surgical time out is meant to reduce preventable errors, and if we take it seriously, it even has the ability to eliminate certain errors. As a resident, the surgical time out has even more to offer – the opportunity to think about case preparation in a systematic manner so that when I’m an attending I can ensure that not only are my cases safe but they are efficient and allow me to provide excellent outcomes by ensuring that I have everything at my disposal which I might need during any given case.
Read more experiences from current residents. Subscribe to our blog!
All of the opinions expressed here are the author’s and his alone, and do not represent necessarily those of Kaplan or its employees.
Test names are the registered trademark of their respective owners.