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Patient Safety Scenario #13: Errors in the Timeout
Captain Rick Saber at the controls. He is a leader in the field of aviation safety and how “crew resource management” made aviation safer.

This essay is the thirteenth installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking” in order to inform and improve our medical safety record. To read earlier essays and learn how to contribute, please click here.

A comparison of safety in aviation and medicine is frightening: aviation disasters are investigated, written up, and every pilot has access to the lessons learned. In medicine, medical errors are investigated, written up, and buried so deeply that no one learns anything. Each surgeon has to repeat every error on their own. On their own patients. This is why now in aviation there is one accident every 2.4 million flights, and why medical errors kill between 44,000 and 98,000 patients per year, according to two good studies reported in the Institute of Medicine report of 1999, To Err is Human. This is the equivalent of crashing a 747 every other day. Would you be willing to fly if this was aviation’s safety record? Yet according to several studies, this is our safety record in medicine. Aviation learned the lesson of Crew Resource Managment in 1979; medicine is just beginning to learn it.

The time-out has been generally recognized as an important contribution to patient safety. However, as these three cases demonstrate, it is not foolproof. I expect that most of us have seen how it can go wrong when the surgeon does not take it seriously, but it can still go wrong when the surgeon takes ownership of the timeout. Situational awareness1 and awareness of how many ways it can go wrong are still needed. In this spirit, the Patient Safety Subcommittee offers this essay to the membership.

David Nelson, MD Chair, Patient Safety Subcommittee
Scott Lifchez, MD Co-Chair, Ethics and Professionalism Committee
Julie Adams, MD Co-Chair, Ethics and Professionalism Committee

Note: The Patient Safety Subcommittee actively solicits scenarios that might be appropriate for future articles. Please send them to: nelsondl@pacbell.net

Case 1

The surgeon scheduled a mucous cyst excision. In the pre-op area, the surgeon verified the side, site, and procedure with the patient, and marked the dorsal aspect of the finger at the DIP joint where the incision was planned. In the operating room, the surgeon ran the timeout, specifying the procedure and pointing out to the team their mark and the patient’s mark. All agreed. The surgeon performed a metacarpal head-level block volarly then went out to scrub, while the OR staff performed the prep and drape. The finger was exposed from the MCP crease distally. The surgeon sat down at the hand table. The prepped hand was lying with the volar injection site exposed.  The surgeon mentally recognized this as the proper block for a trigger finger, and asked for the knife.  The surgeon was about to make a volar incision for a trigger finger release, only to hear the surgical tech state: “I think this is a mucous cyst.” The surgeon’s face turned white as the floor seemed to drop out of the room.

Case 2

In pre-op, the surgeon verified the side, site, and procedure with the patient as a right third finger trigger. The surgeon put his initials on the third finger, alongside the patient’s mark. In the OR, the surgeon ran the first timeout (the hospital insists the timeout be done when the patient is prepped and draped, but the surgeon insists on doing it with the patient awake), stating it was a right third finger trigger. Pt was prepped and draped, the circulator ran the “official” timeout: right third trigger. The team was quite clear about what finger was to have surgery.

The surgeon marked the incision with the pen, asked for the knife, and as the knife was coming down to the skin, noticed that his incision was marked on a different finger than the finger with his initials. He was 1 second away from a wrong site, despite all the timeouts! No one in the room noticed that anything was wrong.

Case 3

A patient with a right distal radius fracture called the office for an ER followup. The surgeon looked up the x-rays online prior to the visit and determined that the fracture was indicated for an ORIF. The surgeon knew that the OR schedule was tight with a holiday coming up, so he filled out an OR scheduling sheet specifying an ORIF of the right radius prior to seeing the patient and the secretary was able to reserve an OR slot a few days in advance. The patient was given an office appointment for the next day. The surgeon saw the patient in the office, examined her, and discussed the radiographic findings and the indications and risks for an ORIF, and the patient decided to proceed with surgery. She also had a history of mild intermittent nocturnal paresthesias prior to the injury, consistent with mild carpal tunnel syndrome. On examination she had some mild numbness in the median nerve distribution. The surgeon discussed that many patients get some increased swelling after the surgery and symptoms may worsen. In addition, the use of long-acting local anesthetics would obscure any post-op signs of compression, so the surgeon suggested a CTR at the same time. She agreed, and signed the consent. The surgeon addressed her questions then filled out “ORIF right radius” on his own form called the Surgical Checklist, which the surgeon created that he fills out in front of the patient at the moment they sign the consent, and later holds in hand when he does the timeout in the OR, so that there could be no mistakes due to a mistake on the OR’s printed schedule.

On the day of surgery there were three ORIF radius cases to do in a row, so the surgeon certainly had “ORIF radius” on his mind. The surgeon spoke to the nurses about turning over the equipment, making sure the operating room had three distal radius fracture implant sets, and that they got the correct side in each case. The surgeon met the patient in the pre-op area and asked his usual, non-leading question, “What are we doing today?” She replied that we were doing an ORIF of the radius, and pointed out her mark, “radius.” The surgeon knew he was doing an ORIF radius, so his placed his mark next to her mark on her right radius. All of her questions were answered. The team came into the OR, and the surgeon ran the pause. The surgeon introduced the patient and read from their own form, named the Surgical Checklist, that they were doing an ORIF of the radius. The patient agreed, as did the team, who were reading off the hospital permit and the OR schedule. The surgery went well.

The patient was discharged to home and seen in routine followup. Her recovery was smooth, she had little pain, and her ROM was improving. At a followup two months later, she mentioned some occasional nocturnal paresthesias, so the surgeon mentioned that she might need a CTR. She said she already had a CTR at the time of the ORIF, so that would not be necessary. The surgeon checked the op note, and verified that they had not done a CTR, only an ORIF, and told her so. She replied that she was sure the surgeon had done one, and pointed to the ORIF incision. The surgeon mentioned that the CTR incision was in the palm, not the forearm. She always thought that the surgeon did the CTR through the forearm incision. The surgeon looked at their Surgical Checklist and the OR scheduling form, both of which said only ORIF radius. She still insisted that she had had a CTR. The surgeon looked at the consent. It was not until then that the surgeon noted the discrepancy between Surgical Checklist & the OR scheduling form, and the consent. The consent was for both procedures, but all the other paperwork was just for the ORIF radius.

The error was started when the surgeon booked her case based on a review of her x-rays for only an ORIF radius, but somehow the surgeon failed to correct the scheduling sheet or put the CTR on any of their paperwork other than the consent. In the pre-anesthesia room, she had only mentioned the radius surgery and her mark only specified the radius surgery. This only confirmed the surgeon’s error, it did not catch it.

Analysis

James Reason is a PhD in industrial psychology and his specialty is how errors happen in the workplace. He has observed that since every human makes errors, any system that is not designed from the beginning to catch errors, is bound to fail. Each system must be designed to catch the inevitable errors, epitomized in the Swiss Cheese Theory of Errors.It is important that both you and the operating room have systems in place to catch errors, with “multiple layers of defense”, as Dr. Reason puts it. But no system is foolproof, as these three cases demonstrate, and you cannot rely on any one layer of defense.  Errors can still happen, even if you are focused on patient safety and write a column on patient safety: the last two cases were mine. The first case was submitted by a friend.

I have made several changes based on these experiences, some of which have also been recommended by many other authors in this field:

(1) The ink must be placed by the surgeon in such a way that the type of case is clearly indicated, and the ink must be visible to the surgeon as the incision is made. Many like to use the marking pen (the purple pens use gentian violet, an antiseptic, as the ink, so the pen cannot cause an infection) to mark the incision as well as their initials.

(2) The patient should be involved in the marking and the time-out, but do not rely on this as the only safety check. Many patients, despite our best efforts to educate them, still do not know the name of their surgery, the location of the incision, and even the side the block should be placed3.

(3) The surgeon should not depend on the hospital/surgery center’s paperwork. It goes through many hands before it reaches the OR suite. The surgeon should have their own original paperwork in hand at the time of the signing of the site and at the time of the timeout.

(4) The time when the permit is signed and the OR schedule form is filled out is a mission-critical moment. Situational awareness is essential: any deviation from the normal routine (the scheduling form was filled out prior to the patient being seen, getting interrupted by a phone call, the patient is a friend, a page from the ER, etc.) is a prime time for an error to enter the system.

(5) The AAOS recommends that the surgeon run the timeout. No one knows better what surgery is to be performed, or how easy it is to do the wrong surgery.

References:

1  Situational Awareness. https://en.wikipedia.org/wiki/Situation_awareness

2  The Swiss Cheese Theory of Errors. https://en.wikipedia.org/wiki/Swiss_cheese_model

3  See the second case in the previous Patient Safety Scenario, https://asshperspectives.org/2018/06/patient-safety-scenario-4-wrong-side-wrong-site-wrong-patient-you-cant-depend-on-the-patient/

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