Timeout process leads to a high reliability organization by preventing errors (mine included)
We have processes in place to ensure that we provide safe quality care to our patients. High reliability organizations adhere to such processes, allowing for the achievement of consistent excellence.
Cleveland Clinic Akron General had exactly that experience during a “timeout” in the operating room that prevented a sentinel event.
One of our neurosurgeons was scheduled to perform a left temporal craniotomy. During the timeout, it was discovered that the left side was incorrect; the procedure was to be performed on the right side. Appropriate adjustments were made and the correct procedure – a right temporal craniotomy – was performed. And a crisis averted.
I have shared with you in the past how the timeout process saved me and other surgeons from making mistakes more than once in the OR. Committing to processes that we know prevent errors is critical. Also critical is having the courage to speak up or question others one-on-one or in a group setting like the OR.
We start each monthly meeting of our regional leaders by reviewing a never or sentinel event, and the lessons learned from it. We do this consistently to learn from each other and to help prevent future errors. The “ask” is that leaders share the information with their hospital teams, so that it is cascaded all the way to frontline caregivers.
After a recent report-out, I turned to Dr. Cynthia Deyling, Cleveland Clinic Chief Quality Officer, who regularly attends the meetings. I asked her how often a timeout was performed appropriately in never or sentinel events. She said never. That may have been a slight exaggeration. But not much.
Leaders create the culture where others can speak up. That is the culture of high reliability organizations.
Congratulations to the Cleveland Clinic Akron General OR staff, in addition to all caregivers who commit to providing safe quality care for our patients.
Importante how the checklist for Safe Surgery is done. You have to avoid overload of work when doing it. Crucial that everybody in the team concentrates on communicating closed loop when the questions are asked. Good work!
This is the equivalent of the ANDON cord in manufacturing...?
The idea of the EHR is a sound one- but it is lack of getting criteria from the end user and its execution that produces potentially fatal errors.
Agree with time out, but I wonder how much the EMR has created errors or the opportunity for errors. The "promise" of the EMR has a long way to go.
It is an international patient safety goal to identify correct patient correct site of surgery