Surgical Safety Checklist

Time-Out
Anesthesia Safety

Vandermeersch E. UZ KULeuven

Anesthesiology only clinical domain to

make patient safety central in its mission

2008

 Check, check and check again

But ask the right questions at the right
time
i.e. before any harm could possibly have
been done and when there still is a way
out

Surgical Safety Checklist 1

Focus on non-emergency surgery

Before induction: Sign In: 1

Patient identity confirmation, site, procedure, consent
last top-up before induction after check when entering OR suite ?
on documents, bracelet, asking patient, alertness after premedication
performer and witnesses : only anesthetist and nurse also for surgery ?
(patient understanding of abracadabra explanation by surgeon some
time ago ? )
Site marked
Anesthesia machine and medication
major (start of day), minor before each case) anesthesia machine check
Pulse oxymeter and functioning
in fact should be monitoring device check
and patient monitoring established before induction to obtain initial
values and to monitor possible adverse reactions during induction:
saturatiion only may be sufficient in the very young but very often is not

Surgical Safety Checklist 2

Before induction: Sign In: 2
Does patient have known allergy, difficult airway/aspiration risk,
blood loss risk
allergy & difficult airway/aspiration risk : detection and drawing
up an anesthesia strategy should be done sufficient time before
the patient is called to the OR
possible blood loss risk in a patient on a regular list should be
anticipated (and measures taken) at time of surgical decision
making or anesthesia screening

Surgical Safety Checklist 3

Before skin incision: Time Out: 1
Teammembers
leading surgeon/others coming/joiningl later
visitors may be acceptable as a last ceremonial action
Patient name, procedure, location of incision
obviously surgeon not present before induction
may only be symbolic and ceremonial/ritual
should be marked on operating list
Antibiotics
OK

Surgical Safety Checklist 4

Before skin incision: Time Out: 2
Anticipated critical events
Surgeon:
critical steps reminder OK
duration should be on operating list
anticipated blood loss too late
Anesthetist:
specific concerns reminder OK
Nurse team:
sterility too late
equipment too late
Essential imaging too late

Surgical Safety Checklist 5

Before patient leaves operating room
Nurse
procedure name what is the use ?
completion of instrument, sponge, needle count OK
specimen labelling nurse checks with surgeon
equipment problems ??
Surgeon, anesthetist, nurse
key concerns for recovery and postop. management
what has OR nurse to do with this ?

Surgical Safety Checklist 6

Fortunately list may be adapted to local practice
Text is of course consensus text to fit (?) the whole
world: surely very different organisational practices and
probably legal constraints according to countries and/or
institutions
Personality of key advisory persons and absence
(excused or not consulted) of certain individuals may
have contributed to strange result
Resulting list is not reality connected and contains trivial
elements
Not logical in timing and content

Surgical Safety Checklist =~

similar to Time-Out procedure
(JCAHO - JCI) ?
JCI phrasing:
--- to ensure correct site, procedure and
patient --Essential processes:
a: marking site, b: preop. verification
process, c: Time-Out
Time-Out is held in the location of and
immediately before the start of a procedure
(incision ?) and involves the entire team

JCI (JCAHO) and Surgical Safety

Checklist requirements with respect
to Time-Out procedure
COMPLETELY DISREGARD
The anesthesia and its nature =
danger of anesthesia

The nature of the specialty Anesthesia:

Pain and apprehension are destabilizing

Surgery is tissue trauma
Tissue trauma is stress response (inflammation)
Stress response destabilizes the body and may have long term
negative effects
The stress response effects continue in the immediate
postoperative period
The position on the table may profoundly affect physiologic
functions
Surgical manoeuvres may profoundly affect the basic
physiologic systems e.g. aortic clamping
Surgery may lead to lasting mutilation and profound functional
impairment e.g. pneumectomy
These effects are superimposed on a possibly already diseased
and aged body

The nature of the specialty Anesthesia:

Anesthesia is then the science and art to shield the body
from the stress response and to preserve the function of
all physiologic systems => STABILITY ! ( BUT

anesthesia effects in se are potentially highly

destabilizing !!!!!!)
Anesthesia goes for SAFE QUALITY SURVIVAL !
What is commonly understood by anesthesia (i.e.
analgesie & sleep) is an element of the strategy to
achieve that goal
In a substantial number of interventions anesthesia is
but a very small part of the strategy the anesthetist
uses to stabilize the body other elements are the direct
manipulation of circulation, respiration and .....

The anesthesia:
At the time of the intervention a number of risk elements come
together:
The patient with his medical background
The actual disease of the patient requiring diagnosis intervention
The preoperative conditioning long and short run
The anesthesia
The anesthetist
The surgery
The surgeon
The nurses
The complex technical environment

This is the time the highest possible skills need to be

available at the action site

AAGBI

RCA

Quality ??
Coats of arms of Anesthesia Societies :
Absentia omnis doloris
Divinum sedare dolorem
Vigilance
In somno securitas
Dormitantes protego
Corpus curare spiritumque
Salus dum vigilamus

+ A lot more !!

The anesthetist:
To achieve that goal the anesthetist has to possess
mental capacities / intellectual skills and emotional
stability
Knowledge, experience and some dexterity
Self-reflection & autocritique
Continuous attention
Anticipation: minutes / seconds
Fast in establishing a diagnosis: seconds
Rapid reaction: seconds
Verification
(complete) change in strategy ?
Earns moral and intellectual authority to take leadership
Has neutral managerial capacities
Diplomatic tact

Quality in anesthesia ?
= Safety First
Primum non nocere

Safety First:
Collaborative document BVAR (academic) BSAR
(professional)
First published: 1989
Revision: 2002
Revision: 2004
Available: website BVAR: for members only
The document describes what equipment, manpower and
procedures are to be used and applied for the
administration of safe anesthesia and it has become a
standard used in litigation to judge departments and
individual conduct

Timing and elements of

Time-Out procedures
and other controls
???????

 Surgical safety depends havily on the quality of the

anesthesia
Anesthesia is not a trivial thing that you impose upon a
patient
People may die from anesthesia: e.g. at induction:
Failure to intubate i.e. failure to oxygenate
Anaphylactic reaction
Hypotension may lead to tissue (myocardial) ischemia
Patients may have received arterial and central venous
lines which may prove unnecessary: these punctures are
not without danger: hemothorax, pneumothorax, .
Can you imagine your case having to be cancelled after
induction

Anesthesia time wasted is a cost but more

importantly
an attack on the integrity
and health of the patient
Anesthesia time wasted waiting for whatever is an
aggression because possible noxious substances have
to be given for a longer time and in higher amounts and
a longer period of possible danger is imposed upon the
patient

Unnecessary prolongation of anesthesia ?

 Before induction of anesthesia all odds should

be in favour of the patient
After induction anything that may abort, delay or
prolong the procedure is to be avoided
Unavailibility of a member of the surgical team
Unavailibility of material
Second/following surgical specialty not
informed/available

A check procedure that may or is meant to

detect anything at all that may result in such a
cancellation, delay or prolongation is stupid if
performed after induction of anesthesia

 Being sheduled and called to the hospital for an

intervention which eventualy will be canceled may harm
patient and society
When being prepared for an intervention a patient may
already suffer harm on the ward: psychologically,
surgical preparation, anesthetic preparation,
A patient erroneously entering the OR suite suffers:
stress, damage from preparatory punctures,
Being put unnecessarily on the operating table means
harm to the patient
Having to cancel the intervention after anesthesia has
been induced is crime pure and simple
Unnecessary delays in the OR, intervention changes not
based on peroperative unexpected findings, other
surgeon doing the surgery than the one the patient
expects is utterly wrong

Avoidance of questioning at moments when harmfull decisions for

patient or organisation may be the result because of lack of
elements: filter questions where the answers may result in a delay
or a change of surgery should be asked long before the patient is
put asleep
Important issues with respect to the intervention and everything
needed preparing for it, should be addressed starting immediately
following the moment the patient is informed of the intervention and
gives consent at every subsequent step in the preparatory period
The establishment of Zorgpaden Trajets de soins may influence
moments and elements
Data must be recorded in a single (continuously updated) file
Passage to next step in becoming definitively sheduled on a OR list
governed by availibility of required elements
Different locations and persons for information gathering ensure
mutual check, corrective action and possibly additional consultations
(surgery consultation, anesthesia consultation, central operating
room scheduler, )

 Certain Time-Out questioning after the patient is asleep,

can only be largely ceremonial
It may serve to accomodate a sloppy general
organisation and personal indolence from one or more
teamplayers (Anesthesia, Surgery, planners, nursing
staff, )
Time-Out / Check procedures in the room, with the
patient on the table, after induction may however
possibly be valuable in emergency cases
Check and rehearsal procedures in the OR may however
greatly improve communication and mutual
understanding of existing and possible problems,
elements of the procedure

 Any Time-Out after an elective patient being brought into

the OR may only be redundant for the essential things
and will/should/can only deal with minor elements
i.e. things not fundamental for actually carrying out the
right intervention, on the right side, on the right patient
but related to events that happen surrounding the actual
stay in the OR
e.g. timely antibiotics given, rehearsal of surgical critical
steps, etc.
If people feel happy with a Time-Out after anesthesia
induction, after positioning, after draping, let it be as long
as very basic decisions may not be the result:
e.g. cancelation of the intervention,
complete change of the nature of the
intervention

Contents of continuously completed

checklist
The patient and all possible elements for
identification: name, residence, ID figures and
characters .
Detailed description of intervention and site(s) of
incision and positioning(s) (no abbreviations
please)
Information on intervention and consequences
given to the patient and/or relatives and
appreciation of their understanding

Contents of continuously completed

checklist
Preoperative anesthesia data available and
complete (only Anesthesia can be responsable)
Day of intervention, room, list number
Medical staff involved
Ancillary care givers: X-ray technicians,
perfusionist, .
Risk of blood loss, blood ordered and available
(stage of blood bank order processing)
Imaging available and ready for display
Equipment available and adequately sterile /
external sources
Projected medical staff available

Contents of continuously completed

checklist

NPO
All other preop. preparations
Room and list number maintained
Medical staff available etc.
Right patient brought to OR
Anesthetist aknowledges reading patient info.
Anesthesia equipment OK
Antibiotics given in time
Etc. .

 Anesthesia is of course willing to contribute to anything

that enhances patient safety and operating room
efficiency
By early contribution in the preoperative period: mandatory
anesthesia consultation
By taking the lead in global OR organisation
By checking on the patient, when he enters the OR without the
surgeon being present, on identity, knowledge on projected
intervention (?), etc. ..

But this also means that every subsequent deviation

from the projected will automatically result in the
anesthetist ordering the intervention to a complete halt
until problem resolved

Prep. for
surg. next
day

First visit
to medic.

Pat. enters
OR suite

Decision
for
surgery

Anesth.
consult.
Intake
hosp.

incision
Pat enters
PACU

Pat. enters
OR

Patient
leaves room
for OR
Anesth.
induc.

Leaves
PACU
End of
surgery
You do not ask for the
antibiotics been given
here

Prep. for
surg. next
day

First visit
to medic.

Pat. enters
OR suite

Decision
for
surgery

Anesth.
consult.
Intake
hosp.

incision
Pat enters
PACU

Pat. enters
OR

Patient
leaves room
for OR
Anesth.
induc.

Leaves
PACU
End of
surgery
You do not ask for the
antibiotics been given
here

You do not ask if you

have the right pat. for
the right intervention
and if all equipment is
available here

Prep. for
surg. next
day

First visit
to medic.

Pat. enters
OR suite

Decision
for
surgery

Anesth.
consult.
Intake
hosp.

incision
Pat enters
PACU

Pat. enters
OR

Patient
leaves room
for OR
Anesth.
induc.

Leaves
PACU
End of
surgery
You do not ask for the
antibiotics been given
here

You do not ask if you

have the right pat. for
the right intervention
and if all equipment is
available here

Prep. for
surg. next
day

First visit
to medic.

Pat. enters
OR suite

Decision
for
surgery

Anesth.
consult.
Intake
hosp.

incision
Pat enters
PACU

Pat. enters
OR

Patient
leaves room
for OR
Anesth.
induc.

Leaves
PACU
End of
surgery
You do not ask for the
antibiotics been given
here