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do before incision.
Case No. 3: Wrong procedure
A caesarean section was planned for delivery of twins at 39 weeks. At the same time, a tubal ligation. The patient consented on the day of surgery, during admit, to the caesarean section and tubal ligation. The twins were successfully delivered; however, the tubal ligation wasn't completed. This wasn't noticed until the patient was in recovery and
the surgeon was reviewing the chart.
When we talk about a robust time out, we mean one that comprises a consistent, evidence-based, human-factors-driven approach. In this case, a good time out could have prevented the wrong surgery.
Every time you do an invasive procedure, there should be a time out that doesn't let team members answer by rote. That is, the time out's questions shouldn't yield such answers as "Yes" or "I agree." The questions should be based on validated source documents, with answers that involve cognitive engagement. For example, "Mrs. Smith is having both caesarean and tubal ligation," or "The knee
arthroscopy will be
