Question

You are the risk manager of a hospital. A nurse from the operating room reports that, during a surgery, the head surgeon did not conduct a “time out” to confirm the side and site of the surgery. You question the surgeon, and he denies the incident. There is no injury to the patient.

What is the nature of the risk?

Who is at risk?

What additional information do you require?

What actions can be taken to prevent recurrence of the incident?

Answer 1

1. NATURE OF RISK :

There are several risks involved when a time out is not done,such as :

• Risk for Wrong surgery.
• Risk for Wrong person.
• Risk for Wrong site of surgery.
• Risk for patient's medical history.

2. WHO IS AT RISK :

The hospital, doctors, registered nurses and the patient himself or herself is at risk.

3. ADDITIONAL INFORMATION :

Additional information before a procedure is done such as drug allergies, if the patient was kept nil by mouth / nil per oral (NBM/NPO), Certain positions to avoid during the surgery.

4. ACTIONS TO PREVENT RECURRENCE OF THE INCIDENT :

• Remind the surgeon or doctors to conduct a time out.
• Receive hand over from the nurse in details.
• Cross check with the patient verbally.
• Make a checklist and maintain it.