ed cardiac devices, and she asks her nurses to go over any and all med-
ication on the back table — and whether there might be issues with
look-alike, sound-alike drugs. "My staff know that I pay attention," she
adds. "That makes them pay attention. And they're not allowed to do
anything else while we do the time out. You can do 2 things at once but
you cannot think about 2 things at once."
Not saying never
Nearly half (46%) of respondents say their facilities have had so-called
never events: An incision on the wrong knee. A burn from an under-
body cautery pad. 100% oxygen given during an ENT case. A laser
event with the wrong eye. An airway fire. Strabismus surgery per-
formed on the wrong eye. A patient burn from an electrocautery wand
left on the patient's abdomen. Right side, wrong finger. A patient
burned by a Bovie. Retained surgical items. The list goes on and on.
Could better communication have prevented any of them? Experts say
that in addition to using time outs and checklists, staff members must
repeatedly be encouraged to speak up when they have concerns.
But it's a struggle to make that happen, say respondents. Fewer than
half (48.2%) say staff members always feel comfortable voicing con-
cerns, and only about one-third (35.6%) say physicians always encour-
age OR staff to speak up if they think something appears to be amiss.
"We're looking into this right now, trying to tell our nurses this is not
a suggestion, but that patient safety depends upon it, and they are
obligated to be a patient advocate," says Greg Rawley, RN, BS, CNOR,
director of nursing at the Algonquin Road Surgery Center in Lake in
the Hills, Ill. "But we do have a few surgeons who are difficult to
approach."
It takes a lot of effort and management support to make it happen,
says Barbara Murdock, RN, nurse manager at Overlake Hospital in
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