Description
Surgical care is delivered throughout the world more than 200 million times annually. The setting for surgical care is disparate occurring in low-resource settings through quaternary care hospitals. While it is hard to quantify the risks of surgery, the burden of a complication happens in millions of cases per year, from minor mishaps to major disasters leading to disability or death. It has been suggested that more than half of all surgical complications are avoidable, such as reduction of infection with prophylactic antibiotics and aseptic technique, and avoidance of wrong-site surgery.
The World Health Organization (WHO) has taken the lead in developing guidelines for practices that can improve the safety of surgical patients worldwide. One key element of the WHO guidelines is the use of a surgical timeout or safety checklist at the beginning of all procedures.
Definition
Surgical timeouts consist of two major elements: A three-part surgical safety checklist—before induction of anesthesia, before the skin incision and before the patient leaves the operating room—and the ability of anyone on the team to call “timeout” if there is some element of the surgery or procedure that needs clarification for safety purposes.
Purpose
The surgical safety checklist, developed by WHO and implemented around the world, is designed to reduce the risk of avoidable patient complications related to procedures. The surgical timeout, which allows any member of the team, regardless or rank (medical student, nurse, anesthetist and surgeon) to stop the procedure and get clarification, was also created for patient safety.
Use
The surgical safety checklist timeout should be used for every case where a patient is going to be given anesthesia or is otherwise unable to speak for themselves. Additional timeouts during a case should be used when necessary to ensure that the team members are in agreement about the progress of the case and care being provided.
NOTE: This entire module is also available in PDF Format.
Learning Outcomes
Students should know what constitutes a surgical timeout and have the ability to run through the elements of the surgical checklist. They should also know why surgical timeouts were created and about highly functioning teams, along with their role on the team.
In obstetrics and gynecology, the student will have many opportunities to witness and participate in surgical timeouts. They will be expected to know the elements of the surgical safety checklist and participate in a culture of safety in their care of patients.
This clinical skills module provides a framework for teaching the importance of and the principles behind the surgical timeout.
At the completion of this module, students should be able to:
- Understand the rationale behind the surgical timeout and safety checklist
- Lead a surgical timeout
Best Practices
Many hospitals will have the surgical safety checklist displayed in the operating room to aid in its completion. In other facilities, an electronic or paper checklist will be utilized with each element being checked off as it is completed.
Before the induction of anesthesia, an anesthesia professional (anesthesiologist and/or nurse anesthetist) and an operating room nurse will orally confirm that:
- The patient has verified their identity, the surgical site and procedure to be performed and has given consent for the surgery
- The surgical site is marked (if applicable)
- The pulse oximeter is on and functioning
- All members of the team are aware of any patient allergies
- The patient’s airway and risk of aspiration have been evaluated and the appropriate equipment and personnel are available
- If there is a risk of significant blood loss (>500 mL), appropriate access and fluids are available
Before the skin incision, the entire surgical team (nurses, surgeons, residents, medical students, anesthesia professionals and anyone else participating in the patient’s care) orally:
- Confirms that all team members have been introduced by name and role
- Confirms the patient’s identity, surgical site and procedure
- Reviews anticipated critical events:
- Critical and unexpected steps, operative duration and anticipated blood loss
- Anesthesia staff reviews concerns specific to the patient
- Nursing staff confirms sterility of operating room, equipment availability and other concerns
- Confirms that appropriate choice of prophylactic antibiotics and time of administration have been given prior to incision or that they are not indicated
- Confirms that all essential imaging results for the correct patient are displayed in the room
- In some hospitals, elements have been added to the checklist ,such as proper placement and functioning of pneumatic compression stockings, a review of important medications such as beta blockers and discussion of the patients glucose level if she is diabetic
After the procedure, before the patient leaves the operating room, the team orally:
- Reviews the name of the procedure performed and recorded
- Confirms that the needle, sponge,and instrument counts are complete
- Confirms that the specimen (if any) is correctly labeled, including the appropriate patient identifiers
- Determines whether there are any issues with equipment that need to be addressed
- Reviews key concerns for the recovery and care of the patient
- Confirms that the surgeon will speak with next-of-kin as requested and instructed by the patient
Checklist
This checklist may be used for teaching and/or for assessment.
|
Done |
Not
Done |
| Definition and purpose |
|
|
| Describes the purpose of the surgical safety checklist |
|
|
| Identifies the three times that the surgical safety checklist is utilized during a surgical case |
|
|
| Performance of the pre-incision surgical safety checklist |
|
|
| Confirms that all team members have been introduced by name and role |
|
|
| Confirms the patient’s identity, surgical site and procedure |
|
|
| Reviews anticipated critical events (critical steps, operative duration and anticipated blood loss) |
|
|
| Confirms with anesthesia staff any concerns specific to the patient |
|
|
| Confirms with nursing staff: A) sterility of OR, B) equipment availability and C) other concerns |
|
|
| Confirms that appropriate choice of prophylactic antibiotics and time of administration have been given prior to incision or that they are not indicated |
|
|
| Confirms that all essential imaging results for the correct patient are displayed in the room |
|
|
Practical Tips
We think that surgical timeouts are performed frequently enough that students will have the opportunity to participate in them during the course of their clerkship. Once the patient is under anesthesia, the student can lead the timeout with supervision, in a real-life and low-risk setting. Alternatively, the timeout could be for a simulated case as part of an objective structured clinical exam at the end of the obstetrics and gynecology clerkship or during a capstone or boot camp course prior to graduation.
Resources
- Haynes AB, Weiser TG, Berry WR, Lipsitz SR. Breiat AS, Dellinger P, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med 2009;360:491-9
- Gawande, A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books. Henry Holt and Company, LLC. New York, NY. 2009.
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