Time Out is conducted immediately before starting an invasive procedure or making the incision and includes all members of the procedure teams in the surgical operating rooms, the Endoscopy suites, and the Interventional Radiology suite. During the Time Out, team members agree, at a minimum, on the following:
- Correct patient identity.
- The correct site.
- The procedure to be performed.
At Regional West, we have taken Time Out one step further to assure patient safety. In addition to the three minimum requirements, other concerns addressed during Time Out include:
- Pre-operative antibiotic.
- DVT prophylaxis.
- Beta Blocker.
Blood availability, implants, X-rays, and other items pertinent to each individual case may also be addressed.
The operating room staff at Regional West is committed to an effective and well-executed Time Out for every patient, every time. All team members are expected to participate with the Time Out process. This means all activity stops during the Time Out. All team members are required to voice agreement or identify discrepancies at this point—everyone in the operating room has equal say in the patient’s safety.
Research shows that one person acting alone has the risk of making one error in every 1,000 attempts. However, two people, working together, risk experiencing just one error for every 1,000,000 attempts. That’s called Cross Monitoring, and those numbers are significant for our patients’ safety.
So what does it mean to “cross monitor?”
Cross monitoring is the process of monitoring the actions of other team members for the purpose of sharing the workload while reducing or avoiding errors.
It means looking out for one another, stepping up and helping one another out, holding others accountable to do the right things, and being willing to tell the other person what he or she did wrong (or better yet, preventing something wrong from happening). We’re all human and we all need help.
The advantages of cross monitoring are enormous:
- It gives nurses the advantage of more eyes and ears to catch things that may escape the attention of one person.
- A second person check or second opinion helps detect unintended slips or lapses, critical thinking problems, and even knowledge and skill deficiencies.
- Cross monitoring reinforces the best practices in each other and provides support during difficult moments.
The Validate and Verify tool is a three-step technique for processing raw information into fact and is a process used by caregivers at Regional West Medical Center to help ensure the safety of each and every patient under our care. In collaboration with Healthcare Performance Improvement (HPI) in our journey to improve safety and reliability at Regional West, the concept of Validate and Verify is explained below.
What is Validate and Verify?
When caring for our patients, we start with available information and the source it comes from. Information can come from a variety of sources:
- Direct observations, such as what we see, hear, or touch.
- Results of tests, such as lab values or images from CT scan, MRI, ultrasound, or X-rays.
- Displays from monitors or devices such as a pressure gauge, temperature gauge, blood pressure monitor, cardiac monitor, etc.
- Verbal and spoken information, such as orders or patient history.
- Verbal and written information that comes from orders or progress notes.
- Guidance documents, like policies and procedures.
The first step in the process is to qualify the information and determine if it came from a source that is both reliable and dependable. Validation is about comparing a situation or information to what you know to be correct and true and determining if it came from trustworthy source. The key to validation is to do it before acting, and to validate every situation and all information before acting.
The second step is to validate the information and determine if the information makes sense. Both qualification and validation of the information are internal checks. It’s that gut feeling or that hunch that something isn’t right. Caregivers at Regional West qualify and validate all information before acting.
The last step of the process is verification. This is the external check where a caregiver checks with an independent and credible source whether the information is correct. If there is a question about the validity of the information, then it will need to be verified. There are three instances in which verification must be performed:
- In every high-risk situation.
- When the caregiver notes an inconsistency.
- When there is a change in a patient’s condition or plan of care.
Medication or treatment mix-ups can be fatal, so at Regional West we use two patient identifiers prior to treatments, procedures, and providing medication. Checking the patient’s hospital wristband for his or her name and birthday are two ways to ensure that the right person is receiving the right treatment, procedure, or medication. Bar code scanning is another way to double check for correct medication.
Cause analysis program
Regional West’s commitment to safety is evident in the newly revised cause analysis program. When a patient outcome represents a serious deviation from the expected outcome, Regional West investigates the event to identify potential problems and opportunities for improvement.
The cause analysis process reveals any shortcomings embedded in standards, expectations, procedures, processes, and behaviors. Regional West uses the information from these investigations to define recommendations for corrective actions to prevent the problem from recurring. Additionally, the hospital reviews cumulative cause analysis data over time to identify common themes and potential system issues.
Self-checking tools are designed to help prevent errors from occurring when doing routine tasks in auto pilot mode. Regional West uses two tools to prevent errors in this mode: STAR and Continuous Use Job Aides.
Star is a self-checking tool that helps prevent errors during routine tasks.
- Stop—Pause for one to two seconds.
- Think—Visualize the act.
- Act—Perform the task.
- Review—Check the response.
Research has shown that just a one to two second pause can greatly reduce chances of error. The best times to use STAR is when going from thought to action.
Continuous Use Job Aides
Continuous use job aides are ‘to do’ lists, check lists, or flow sheets that list tasks or action steps for infrequently performed or high-risk procedures. Job aides in health care include drug handbooks for medication information, procedures and protocols for specific tasks, and pre-surgical checklists, to name just a few. Continuous use job aides help insure that no steps are missed and reduce the probability of error.
Not hearing or understanding information clearly and/or forgetting to pass along important information is a safety risk that we work hard to prevent at Regional West. The Communication Bundle has several tools that help us communicate more clearly and avoid errors. The bundle includes:
- Three-Way Repeat Backs.
- Phonetic and Numeric Clarification.
- Ask Clarifying Questions.
- Encourage Questions.
- Hand off using SBAR.
Three-way repeat backs ensure that all information has been heard correctly. Phonetic clarification is used to make sure that we have the correct patient names, drug names, and procedure names. Numeric clarification is used to make sure the correct dose of medication is given or that we hear the correct lab value. It’s important that both health care workers and our patients are on the same page, and so we ask clarifying questions and encourage questions.
SBAR is a communication tool and stands for Situation, Background, Assessment, and Recommendation. As health care professionals, it helps us remember specific types of information that needs to be communicated, as well as communicating information that requires action, like reporting something unusual about a patient to the physician, or calling Facilities Management to repair a piece of equipment. SBAR communication format is also used during hand-off of the care of the patient from one person to another.
ARCC is a tool used at Regional West whenever any care provider thinks that an apparent plan of action is not in the best interest of a patient. It stands for:
Ask a question
Make a Request
Voice a Concern (if no success)
Use Chain of command
Speak up for safety using this technique was first used in commercial aviation to help co-pilots speak up to captains if they felt there was room for concern. If a simple question does not work then the person voicing the concern uses the official ‘safe’ word, which is “concern.” “I have a concern” or “I’m concerned with.” The technique is intended to start with an earnest question and progressively increase in assertiveness until the condition prompting the question is resolved to the satisfaction of all.