Background
The Minnesota Hospital Association (MHA) and
the Minnesota Department of Health (MDH) have reviewed data from
the adverse health
event
reporting system
and have noted that in 38 percent of
wrong site procedures reported since October
2009, the correct
site was marked by the person
performing the
procedure, however, the
site mark was
not located, and its location shared with
the
procedure team, as part
of the time-out
process. Root cause analyses reviewed indicate that
in most cases the site mark was
not visible after prepping and draping
and the team proceeded
with the procedure without
looking for and locating the site mark.
Recommendation
Marking the site of
a surgical or invasive
procedure prior to
initiation
of the procedure is
a crucial step in the verification process. However,
if that
site mark is not visualized
during the time-out
process,
the value of this step is undermined and the final opportunity to
prevent a wrong-site or wrong procedure incident
may
be missed. The community standard for time-out
in Minnesota includes visualization and verbal confirmation
of the site mark by a member of the operative team as part of
a robust, active time- out process.
MHA and MDH
recommend that facilities revisit their
surgical and other invasive procedure
policies
and processes to clarify responsibilities
for
locating the site marking prior to
procedure start as part of
the time-out process. It is
also recommended that observational audits
be performed to observe whether or
not this step of
the process is
being
completed on a consistent
basis.
The Minnesota
time-out recommendations include the
following steps:
-
Surgeon: Initiates
the time-out
4
- Circulator: Reads aloud
the patient’s
name, 2nd identifier,
procedure and procedure site from
the informed
consent document that has been previously verified during pre-op
and asks the team to verify.
- Anesthesia
Care Provider:
States patient’s name, 2nd patient identifier
and
procedure (can
be short-hand version of the procedure) with laterality if appropriate.
- Scrub Person: 1st –
Verifies
which procedure they have prepped —
can
be a
shorthand version of
the procedure; 2nd – Visualizes the mark, verbally indicating that he/she
sees the mark
and where it
is
located.
- Surgeon: States full procedure; asks scrub person to remove
the time-out towel
to begin the
procedure.