conducting-surgical-time-outs

# Conducting Surgical Time-Outs

Structures WHO surgical safety checklist completion with sign-in, time-out, and sign-out documentation.

## Why This Skill Exists

The WHO Surgical Safety Checklist, introduced in 2008 as part of the "Safe Surgery Saves Lives" campaign, reduced surgical mortality by 47% and complications by 36% in the original implementation study (Haynes et al., NEJM 2009). The Joint Commission's Universal Protocol mandates a pre-procedure verification, site marking, and time-out for every invasive procedure. Wrong-site, wrong-procedure, and wrong-patient events remain sentinel events that trigger mandatory Root Cause Analysis and reporting to state health departments.

Despite the proven benefit, compliance with the full three-phase checklist (Sign-In, Time-Out, Sign-Out) remains inconsistent. Common failures include treating the time-out as a formality without active team participation, failing to complete the Sign-Out phase, and not documenting checklist completion in the medical record. This skill standardizes checklist execution and documentation to ensure every phase is performed meaningfully and recorded completely.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What procedure is planned and is laterality involved? **Default: [VERIFY — obtain from consent and booking sheet]**
2. Has the surgical site been marked by the operating surgeon? **Default: [VERIFY]**
3. What is the patient's identity verification method (wristband, verbal confirmation)? **Default: wristband + verbal**
4. Has the patient confirmed the planned procedure and site? **Default: [VERIFY]**
5. Is the consent form signed and available in the chart? **Default: [VERIFY]**
6. What is the patient's allergy status? **Default: NKDA**
7. Has the anesthesia team completed their machine and airway assessment? **Default: [VERIFY]**
8. Are there any anticipated critical events or special equipment needs? **Default: none**

### Documents to Request

- Signed surgical consent form
- Surgical booking/scheduling confirmation
- H&P with documented laterality
- Preoperative nursing assessment
- Anesthesia pre-assessment form
- Relevant imaging with laterality markers displayed
- Blood product availability confirmation (if applicable)

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## Step 1: Sign-In Phase (Before Induction of Anesthesia)

The Sign-In is performed before anesthesia induction, with at minimum the anesthesia professional and circulating nurse present. The patient must be awake and able to participate.

**Required verification elements:**

| Element | Action | Documentation |
|---|---|---|
| Patient identity | Confirm name and DOB using two identifiers | Wristband checked, patient verbally confirmed |
| Procedure and site | Patient states planned procedure and side | Matches consent and booking |
| Site marking | Operating surgeon's mark visible on correct site | Present, confirmed by patient |
| Consent | Signed consent in chart | Verified by circulating nurse |
| Pulse oximeter | Functioning and attached before induction | Confirmed |
| Known allergies | Reviewed aloud | Listed or NKDA stated |
| Difficult airway/aspiration risk | Anesthesia assessment | Equipment available if yes |
| Risk of blood loss >500 mL | Surgeon's estimate | Blood products available, two large-bore IVs confirmed |

**If ANY element cannot be confirmed, the Sign-In must stop and the concern must be resolved before proceeding.**

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## Step 2: Time-Out Phase (Before Skin Incision)

The Time-Out occurs after positioning, prepping, and draping but BEFORE the incision. All team members must stop work and actively participate. A passive or concurrent time-out does not meet Joint Commission standards.

**Required elements — spoken aloud by the circulator and confirmed by each team member:**

1. **Team introduction**: Each member states name and role (required for the first case; recommended for every case)
2. **Patient identity**: Re-confirmed (name, DOB)
3. **Procedure confirmation**: Exact procedure as listed on the consent form, including laterality and any planned variations
4. **Surgeon statement**: Anticipated critical steps, expected duration, anticipated blood loss
5. **Anesthesia statement**: ASA classification, any patient-specific concerns (difficult airway, cardiac history, allergy issues)
6. **Nursing statement**: Sterility of instruments confirmed, equipment issues, implant availability verified
7. **Antibiotic administration**: Confirm given within 60 minutes of incision (or 120 minutes for vancomycin/fluoroquinolones); name and time documented
8. **DVT prophylaxis**: SCDs applied and functioning
9. **Essential imaging**: Displayed in OR and confirmed by surgeon
10. **Patient warming**: Active warming device in place

Document the time-out time, participants, and confirmation of all elements. Any unresolved concern must halt the procedure.

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## Step 3: Sign-Out Phase (Before Patient Leaves the OR)

The Sign-Out occurs before the patient leaves the operating room. The surgeon, anesthesia provider, and circulating nurse participate.

**Required elements:**

1. **Procedure name confirmation**: The procedure actually performed is recorded (may differ from planned)
2. **Instrument, sponge, and needle counts**: Confirmed correct by the circulator and scrub
3. **Specimen labeling**: All specimens correctly labeled with patient name, MRN, anatomic site, laterality, and container number — read back to the surgeon
4. **Equipment problems**: Any equipment malfunctions documented for biomedical engineering
5. **Key recovery concerns**: Surgeon and anesthesia team communicate specific postoperative orders, monitoring needs, and anticipated complications to be watched for in PACU

If count discrepancy exists at Sign-Out:
- Search the field, drapes, trash, and floor
- If item not found, obtain intraoperative X-ray before the patient leaves the OR
- Document resolution or retained foreign body investigation in the operative report

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## Step 4: Documentation and Compliance Recording

Record checklist completion in the medical record using the institutional documentation method:

- **Paper-based**: Complete the printed WHO checklist form; place in the chart
- **EHR-based**: Complete the electronic safety checklist module; sign electronically
- **Hybrid**: Complete the paper form in the OR; scan into EHR within 24 hours

Documentation must include:
- Name of the person who led each phase
- Time each phase was completed
- Names of participants in the Time-Out
- Any concerns raised and their resolution
- Count status at each required count point

For quality monitoring, track compliance metrics:
- Percentage of cases with all three phases completed
- Time-out duration (target: >60 seconds of active discussion)
- Incidence of cases where concerns were raised and resolved

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## Step 5: Special Scenarios and Adaptations

### Multiple procedures by different surgical teams
- Perform a separate time-out before EACH new procedure
- Re-verify patient identity, procedure, site, and antibiotic coverage for each segment

### Emergency cases
- Complete an abbreviated time-out — at minimum: patient identity, procedure, site, allergies, antibiotic given
- Document that an emergent situation precluded the full checklist; complete remaining elements as soon as clinically feasible

### Local/regional procedures outside the main OR
- The Universal Protocol applies in ALL locations where invasive procedures are performed (endoscopy suite, interventional radiology, bedside procedures)
- Adapt the checklist to the setting while preserving the three phases

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Were all three phases (Sign-In, Time-Out, Sign-Out) completed and documented?
2. Was the time-out an active pause with full team participation, not a background recitation?
3. Was antibiotic administration timing confirmed and documented?
4. Were all count statuses documented, including resolution of any discrepancies?
5. Were any concerns raised during the checklist resolved and documented before proceeding?

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## Quality Audit

- [ ] Sign-In completed before induction with patient participation
- [ ] Two-identifier patient verification performed and documented
- [ ] Surgical site marked by the operating surgeon and confirmed by patient
- [ ] Consent form verified as signed and correct
- [ ] Time-Out performed before incision with all work stopped
- [ ] All team members introduced by name and role
- [ ] Antibiotic administration documented with drug name and time relative to incision
- [ ] DVT prophylaxis confirmed (SCDs applied and functioning)
- [ ] Essential imaging displayed in OR
- [ ] Sign-Out completed before patient leaves OR
- [ ] Instrument, sponge, and needle counts confirmed correct
- [ ] Specimen labeling verified with read-back
- [ ] All three phases documented in the medical record with times and participants
- [ ] Count discrepancy investigation documented (if applicable)
- [ ] Equipment malfunctions reported to biomedical engineering

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## Guidelines

1. The Time-Out must be an active pause — all team members stop what they are doing, face each other, and participate verbally. A time-out performed while the surgeon is scrubbing or the anesthesiologist is documenting does not meet the standard.
2. Any team member can initiate a "stop the line" if they have a safety concern at any point during the checklist. This must be treated as a non-punitive event.
3. The surgeon who will make the incision must be present and participate in the Time-Out — a resident or PA cannot substitute for the attending during this phase.
4. For laterality cases, the surgical site mark must be visible after draping. If the mark is not visible, remove drapes to confirm before proceeding.
5. Antibiotic timing is a CMS core measure: the antibiotic must be fully infused within 60 minutes before incision (120 minutes for vancomycin or fluoroquinolones). Document the actual infusion start and completion times.
6. Never skip the Sign-Out phase — this is the most commonly omitted phase and is where specimen labeling errors and retained foreign bodies are caught.
7. For cases involving implants, verify the implant type, size, and lot number during the Time-Out phase and again during Sign-Out.