Page 53 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

sentinel events of the year. From 2005 to 2016, a total of 1,281
20
wrong patient, wrong site, or wrong procedure sentinel events
have been reported to The Joint Commission, underscoring

the crucial need for effective preoperative communication and
planning for surgical teams.
21

Some errors related to misuse of time-outs/checklists as

determined by The Joint Commission include the following:

• Time-outs occurring before all staff members are ready or

before prep and drape occurs

• Performing time-outs without full participation of the staff

• Lack of senior leadership engagement in the time-out

• Staff feeling passive or unable to speak up

• Inconsistent organizational focus on patient safety

• Policy changes made with inadequate or inconsistent staff
education

• Distractions or rushed time-outs

20 http://bulletin.facs.org/2017/06/time-outs-and-their-role-in-improving-safety-and-quality-in-
surgery/
21 https://psnet.ahrq.gov/webmm/case/177/the-inside-of-a-time-out

Page 53