Minnesota Safe Surgery Coalition
• Coalition Goal: Eliminate Wrong Site, Wrong
Procedure and Wrong Patient Events within 3
Years.
• Members
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Minnesota Hospital Association
Minnesota Department of Health
Minnesota Medical Association
Minnesota Medical Group Management Association
MMIC Group
The Minnesota Time Out Campaign
• Phase 1 of the Safe Surgery Project
• Targets Wrong Site Events
– Objective: Administration, physicians and
front-line staff will join together to hold each
other accountable for conducting robust,
effective Time Outs for every patient, every
invasive procedure, every time.
• Kick-off on National Time Out Day (June
15)
Why is the Campaign Necessary?
• Reports of adverse events involving procedures
performed on the wrong site/side/level have been
increasing in Minnesota.
• Last year, 66% of wrong site procedures were on the
wrong side (right vs. left).
Sample Minnesota Events
• The Anesthesia Care Provider inserted the needle to
perform an anesthesia block. The patient felt a twitch in
their leg and stated that the twitch was on the left side and
the surgery should be on the right side. The patient was
correct.
– No site marking or Time Out had been performed for the block.
• Site mark for right stent placement placed on arm and
was not visible after prepping and draping. Left stent
placement performed.
– Site mark was not visualized during the Time Out.
Sample Minnesota Events
• Surgeon consulted on patients in two different rooms.
Surgeon performed knee aspiration on incorrect side
thinking it was the other patient.
– Patient identity was not verified and Time Out was not performed.
• Patient consented to left knee arthroscopy. Right leg
placed in holder and tourniquet placed. Surgical site had
been marked but when initials were not seen on the right
leg surgeon thought marked was removed by surgical
prep.
– Site marked was not visualized during the Time Out.
Sample Minnesota Events
• Patient consent for a right knee arthroscopy. All
documents indicated right knee and right knee was site
marked by surgeon. Surgeon and nurse put leg holder on
left side of table and positioned left leg in holder. Left
knee injected, prepped and draped. Time Out conducted
and incision made to left knee. When nurse started
documentation, she noted that the left knee was intended
and informed the surgeon.
– Site mark was not visualized during the Time Out. All members of
the team were not engaged in the Time Out process.
Why Focus on Time-Out?
• Almost all of the 2010 wrong site procedures in Minnesota
were breakdowns in basic best practices - primarily in the
Time Out process.
• Observational studies of time out in Minnesota ORs show
that:
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Site mark not visualized
Source documents not referenced
Stating “I agree” rather than independent verification
In a number of instances, such as an anesthesia block prior to
a surgical procedure, there was no process in place to conduct
site marking and a Time Out.
Development of MN Time Out
• Developed by University of MN Center for
Human Factors Research and Design
• Observed 58 procedures across 8 hospitals
• Direct observations
• Focus groups
Addressing Gaps
• MN Time Out addresses observed gaps
– Uncertainty about initiation
– No cessation of activity
– No acknowledgement of accuracy of
information
– No referral to source documents
– No or incorrect site marks
– Team members not cognitively engaged
Minnesota Time Out
Step
Rationale
1. Person performing procedure initiates
The team is more likely to cease activity
and come together for the Time Out.
2. Team ceases all activity
Active listening/participation.
3. Designated staff, other than person
performing procedure (OR – circulator),
verbally states patient name, procedure
and location while referring to source
documents. (In the OR, ACP also
provides patient name and procedure
from their documentation).
-Surgeon is the last to verify to control
for hierarchy/power differential, i.e. if the
surgeon states information first, the team
is more likely to agree rather than provide
independent verification.
-Source documents have been verified
prior to the procedure and should be an
accurate source of information.
4. Designated staff, other than person
performing procedure (OR – scrub),
locates and verbally confirms
visualization of site mark and states
where it is located.
-Providing an active role (rather than “I
agree”) for all team members counters
rote recitation. -Team members more
likely to be cognitively engaged in the
process.
5. Person performing procedure verbally
states procedure including location from
memory.
Decreases memory interference to focus
on this procedure.
Call to Action for Physicians
• All steps of the Time Out must be conducted
before every invasive procedure for every
patient, every time.
– Key areas where a Time Out is not consistently
applied across the state:
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OR procedures
Blocks and injections prior to OR procedures
Stand alone anesthesia blocks
Interventional radiology procedures
Stop the Line Practice
• Any person who observes or becomes aware of harmful situation in
patient care has the authority and responsibility to speak up and
request the process be stopped in order to clarify the patient safety
situation.
– This person needs to say in a firm, clear and respectful manner: “STOP,
I have a patient safety concern.”
– Staff are to assertively voice concern at least two times to ensure the
request has been heard.
• If there is noncompliance to respond to this time out, the Chain of
Command process is invoked.
Success stories
• An elderly patient undergoing repair of a hip fracture was
prepped for a right-sided procedure, consistent with the
consent, history and physical, and a consultation report.
During the time out, the surgical team determined that
the patient had a left hip fracture, which was then
confirmed by x-ray. The procedure was performed on the
correct side.
• Wrong knee was marked in pre-procedure area.
Verification of the site marking against source
documents uncovered the discrepancy and correct site
was marked and surgery completed.
Take-Home Points
• A Time Out must be completed prior to any invasive
procedure across the organization for every patient,
every time.
• All Time Outs must be completed following the 5 key
steps in the Time Out process.
• If there are any discrepancies during the Time Out or a
step is not completed, members of the team will “Stop
the Line” until resolution and agreement by the team.
• Staff and physicians will be supported by administration
in “Stopping the Line.”