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F E B R U A R Y 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
Above and beyond?
Some procedures present special challenges when it comes to main-
taining focus, says Dr. Ring. In those cases, having just one time out
might not be enough. Among the many factors ramping up the confu-
sion that led to his wrong-site surgery were a room and staff change.
"Having that in the middle of a short procedure was distracting," he
says.
Maybe staff changes during procedures should be prohibited.
"That's a big topic of debate," he says. "I think there have to be
changes during very long procedures, but they shouldn't change for
shorter procedures — anything under an hour and a half, or even 2
hours."
And when procedures last 6 or 8 or 10 hours? "Somebody sneaking
in and saying hi and somebody else saying bye is probably not ade-
quate. There should be a more formal system to make sure things
don't get missed or misunderstood in the transition. Every time there's
a change, do a hard stop time out. Introduce the new members of the
team, have everybody check on where they're supposed to be: How is
the anesthesiologist doing? How are the nurses doing? How is the
patient doing? Are there any technical problems? Make sure every-
body understands where they are and feels good about the current
P R E - O P S A F E T Y
'Every time there's a change, do a hard
stop time out. Introduce the new
members of the team. Have everybody
check on where they're supposed to be.'
— David Ring, MD
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