3 thoughts on “Policy Options Brief on New Methods for Conducting Safety Checks in the Operating Room”
Communication is such an important skill in all situations. As a nurse, lack of communication is such a serious problem within healthcare. Just recently as nurse felt guilty they didn’t call a ‘Time Out’ during a procedure because they didn’t want to be deemed as the ‘bad guy’ and be looked at negatively. Unfortunately, complications occurred as no ‘Time Out’ was called and the surgical professional ignored the sublet plea of the nurse to stop the procedure. It was definitely preventable, which is why it has caught the attention of WHO, Joint Commission, and CMS.
I like that there is an option to educate ALL surgical professions such as the surgeons themselves and anesthesia. As you mentioned, it is going to be a cultural change to be adopted by the healthcare professionals. That is going to be the hard part. Our hospital had a mandatory safety meeting for all healthcare staff, which included the ‘Time Out’ initiative and many left the meeting laughing and mocking it. It is a challenge.
I find the monitor for time out very interesting. I had to go on Youtube to see what a time out in the operating room is. I can see this being very effective. Are there hospitals that already implemented this?
After reading this memo I do believe that this is a serious problem that should be addressed. I was formally an Veterinary Technician in a high quality, high volume spay and neuter program run by a non –profit and can even see something like this being implemented in that surgical room. Addressing this issue is extremely important because it makes not only the doctors, but also the operating room nursing staff accountable for the patient’s wellbeing during surgery. This memo also reminded me of a book I read called “The Checklist Manifesto” by Atul Gawande. It talks about the importance of having a planned out procedure that is standardized in the medical field. These protocols help in avoiding unnecessary mistakes and possible patient complications in the hospital setting.
I think that these options so far are good. The most relevant one would the Time- Out supported option. I think that this is really important and holds the surgery at a very high standard. I like that in this option there are posters that can be placed as reminders to other staff of what will be required. I think what would be helpful to note is the extra time that this will take during surgery. Will have an effect on the overall time that the patient is under anesthesia. I think it’s also important to note how this option would be implemented in the case of an emergency surgery. Will it take the same amount of time, or will there be a separate ER protocol for Time- Out?
Mary and Maria,
Great policy proposal.
1) Is the case for the seriousness of the problem sufficient? If not, how could it be stronger?
— I definitely think you’ve developed a strong case about an issue that needs to be routinely addressed and reinforced. You addressed your Policy Brief to “Chief of Staff, Surgery and Vice President of Peri-Operative Services”. Maybe this case can be specifically presented stronger to an institution that is currently struggling, or showing high incidences of “never events” that occur from poor time out.
2) Can you think of any options not mentioned by the author(s) that might solve the problem? What are they?
— I think the poster and computer in the room are great tools to carry out a proper time out. I personally love the computer in every OR room idea more. I think we can even maximize this computer for not only time-outs, but for other opportunities as well. . Maybe medical students/residents can “Skype” in on a live surgery (granted consent, of course), etc.
— To reinforce the effectiveness of performing time out procedures, I also think the idea of having a “black box” in the OR might be useful, similar to what they use on airplanes if an aviation error occurs. If a “never event” does occur, perhaps management can reference back to the time out procedure, etc.
3) Do you have all the information you need to make a decision about which option(s) to choose? What more would it be helpful to know.
— Adequate information is provided. I am curious to know how much of the “never events” occur because of lack of time out or from other various causes. Also, if there are research studies that show improvement rates from time-out initiatives.
4) Which option or options seem best to you? Why?
— Of the options presents, I like the computer system the best. It has the potential to provide the best outcomes for time-out, plus more.
Communication is such an important skill in all situations. As a nurse, lack of communication is such a serious problem within healthcare. Just recently as nurse felt guilty they didn’t call a ‘Time Out’ during a procedure because they didn’t want to be deemed as the ‘bad guy’ and be looked at negatively. Unfortunately, complications occurred as no ‘Time Out’ was called and the surgical professional ignored the sublet plea of the nurse to stop the procedure. It was definitely preventable, which is why it has caught the attention of WHO, Joint Commission, and CMS.
I like that there is an option to educate ALL surgical professions such as the surgeons themselves and anesthesia. As you mentioned, it is going to be a cultural change to be adopted by the healthcare professionals. That is going to be the hard part. Our hospital had a mandatory safety meeting for all healthcare staff, which included the ‘Time Out’ initiative and many left the meeting laughing and mocking it. It is a challenge.
I find the monitor for time out very interesting. I had to go on Youtube to see what a time out in the operating room is. I can see this being very effective. Are there hospitals that already implemented this?
After reading this memo I do believe that this is a serious problem that should be addressed. I was formally an Veterinary Technician in a high quality, high volume spay and neuter program run by a non –profit and can even see something like this being implemented in that surgical room. Addressing this issue is extremely important because it makes not only the doctors, but also the operating room nursing staff accountable for the patient’s wellbeing during surgery. This memo also reminded me of a book I read called “The Checklist Manifesto” by Atul Gawande. It talks about the importance of having a planned out procedure that is standardized in the medical field. These protocols help in avoiding unnecessary mistakes and possible patient complications in the hospital setting.
I think that these options so far are good. The most relevant one would the Time- Out supported option. I think that this is really important and holds the surgery at a very high standard. I like that in this option there are posters that can be placed as reminders to other staff of what will be required. I think what would be helpful to note is the extra time that this will take during surgery. Will have an effect on the overall time that the patient is under anesthesia. I think it’s also important to note how this option would be implemented in the case of an emergency surgery. Will it take the same amount of time, or will there be a separate ER protocol for Time- Out?
Mary and Maria,
Great policy proposal.
1) Is the case for the seriousness of the problem sufficient? If not, how could it be stronger?
— I definitely think you’ve developed a strong case about an issue that needs to be routinely addressed and reinforced. You addressed your Policy Brief to “Chief of Staff, Surgery and Vice President of Peri-Operative Services”. Maybe this case can be specifically presented stronger to an institution that is currently struggling, or showing high incidences of “never events” that occur from poor time out.
2) Can you think of any options not mentioned by the author(s) that might solve the problem? What are they?
— I think the poster and computer in the room are great tools to carry out a proper time out. I personally love the computer in every OR room idea more. I think we can even maximize this computer for not only time-outs, but for other opportunities as well. . Maybe medical students/residents can “Skype” in on a live surgery (granted consent, of course), etc.
— To reinforce the effectiveness of performing time out procedures, I also think the idea of having a “black box” in the OR might be useful, similar to what they use on airplanes if an aviation error occurs. If a “never event” does occur, perhaps management can reference back to the time out procedure, etc.
3) Do you have all the information you need to make a decision about which option(s) to choose? What more would it be helpful to know.
— Adequate information is provided. I am curious to know how much of the “never events” occur because of lack of time out or from other various causes. Also, if there are research studies that show improvement rates from time-out initiatives.
4) Which option or options seem best to you? Why?
— Of the options presents, I like the computer system the best. It has the potential to provide the best outcomes for time-out, plus more.