Take Time Outs to Avoid Mistakes



Bryan E. Bledsoe, DO, FACEP | | Monday, March 22, 2010

Not long ago I read a story about a competent surgeon, at a well-respected hospital, who operated on the wrong extremity. Similarly, in EMS, there have been numerous reports where experienced paramedics have pronounced patients dead on the scene, only for them been found to be alive later. These are the sorts of stories the media loves to publish and the public loves to ridicule. How do experienced surgeons and experienced paramedics make seemingly simple errors?

The answer is somewhat complicated -- but explainable. As one masters a skill or medical procedure, performing it almost becomes automatic. For example, an experienced paramedic can place an endotracheal tube without really thinking through the steps of the process. This is desired and constitutes mastery of the procedure. However, even though we have mastered the procedure, we still follow (perhaps subconsciously) a step-wise order and process in our mind. Any time this process is interrupted, we can lose track of where we are in the process, and this opens the door to potential error. Humans are not infallible. Even the most skilled and the most educated people will still make mistakes.

Several years ago, operating room (OR) nurses recognized an increased incidence of preventable surgical errors and developed steps to reduce their frequency. The process they developed is simple, and its's called a "time out." This procedure is now routinely utilized in many ORs for all high-risk procedures.

For example, a surgeon and the OR team prepare to operate on a patient's shoulder. Prior to making the incision, the surgeon and the entire OR staff take a time out and check that they have the right patient, the right surgical area, the right instruments, and the proper anesthesia and monitoring. Once this has been assured, and all are in agreement, the operation is started. This has proven to be an effective tool in minimizing surgical errors. In fact, the Joint Commission, the organization that accredits health-care facilities, has recommended this time out process to hospitals as a part of the accreditation process. Perhaps it has a role in EMS as well.

Several procedures in EMS are considered high risk. These include endotracheal intubation, refusal of service situations, death pronouncements, physical restraint and motor vehicle operations. For example, when an EMS crew receives an emergency call, they typically jump in the ambulance and go through an automated ritual that often includes removing electrical landlines and vehicle exhaust scavenging systems, checking a map or computer and fastening seat belts. However, suppose that during this process a citizen walks up to the ambulance and interrupts this ritual with a question. This interruption can cause the crew to forget (subconsciously) to perform crucial and common-sense steps, such as removing a landline wire or fastening a seat belt. Before putting the ambulance in motion, the crew should take a quick time out and assure all preparations have been made. This is very similar to what occurs in aviation. Prior to high-risk procedures, such as takeoffs and landings, pilots will go through a checklist to ensure that seemingly intuitive procedures (e.g., lowering landing gear) have been completed.

I encourage EMS systems to consider requiring the time out strategy for all high-risk procedures. Ensuring that the proper steps have been taken will help to minimize errors. Also, documenting in the run report that the crew took a time out prior to starting a dangerous or risky procedure shows that the crew made patient safety a priority, and that can help defuse future problems. Thus, before you get busy, it might be best to take a time out. In the overall scheme of things, it'll be worth it.

To read Bledsoe's column about the run report,click here.

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