Minnesota Hospital Association

Quality & Patient Safety

July 31, 2006

Minnesota Adverse Health Event Alert: Conducting a Pre-Operative Checklist/Effective "Time-Out"


Minnesota Hospital Association (MHA) has reviewed data from hospitals that have agreed to share adverse health reporting information and has noted commonalities in submitted root causes for wrong body part surgical events. The majority of root cause analyses indicate that a “Time-Out/Pause for the Cause” prior to the invasive procedure, regional block, or surgery was either not conducted or was not effectively conducted.


MHA recommends that all hospitals implement the Safest in America/Institute for Clinical Systems Improvement Safe Site Protocol for Invasive and Surgical Procedures that was updated in January 2006: [see PDF]. The protocol is consistent with the JCAHO Universal Protocol and provides additional specifications, special considerations and a Surgical Procedure Checklist [see Word DOC] and a Non-OR Invasive Procedure Checklist that can be incorporated into pre-procedure processes: [see Word DOC].

Hospitals have found increased success with completion of the protocol steps by automatically printing out these pre-procedure checklists along with their informed consent documents to help ensure that the checklist is completed for each surgical and invasive procedure. Hospitals have shared additional learnings to help ensure that the “Time-Out” or “Pause for the Cause” component of the checklist is successfully completed. The “Time-Out” should:

  • be completed just prior to the procedure;
  • be conducted in a quiet environment — no talking, music, etc;
  • include active participation by the full team — all members of the team should know that they can safely speak up if they suspect a problem; and
  • include one individual who is responsible for ensuring that the pause is conducted.

Based on information reported into the Patient Safety Registry, the Minnesota Hospital Association has worked with the members of MHA’s Patient Safety & Registry Advisory Council to prepare this alert.   

For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393.