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What’s New in the Patient Safety World

May 2020

Timeout Compliance: Ring a Bell?



When we review cases of wrong site surgery (wrong site, wrong patient, wrong side, wrong procedure), we often find that the surgical “timeout” was either not performed or was performed without the full attention of the entire OR team (or team in the procedure room). Every member of the team is expected to take an active role in the timeout. Responses should not be passive nods of assent. Verification should rely upon primary source documentation and not be second-hand. And any member of the team who has questions should be empowered to stop the procedure. The timeout should take place in accord with the “sterile cockpit” concept we’ve adopted from the aviation safety movement.


A recent review of surgical timeouts, using direct observation, found that at least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures (Freundlich 2020). That shouldn’t surprise most of you. That’s a rate we commonly encounter at many hospitals or ASC’s or cath labs. We’ll bet most of you don’t actually know how often this happens because you don’t actually measure this important item. Measuring it by way of OR video monitoring is one of the prime reasons we have long advocated video recording in the OR (see our columns on video monitoring listed below).


In the study by Freundlich et al. the frequent distractions occurred despite the fact that most timeouts were completed in less than one minute. They did perform a timeout before the first incision in 100% of cases and there was a formal announcement that the timeout was about to start in 163 of 166 observed surgeries. 92.8% of their timeouts were completed without interruption (the most common reason for an interruption was to verify patient information). Ten time-out procedures were stopped due to a safety concern. Fortunately, there were no wrong-site or wrong-person surgeries reported at their hospital during the study period.


We once, in a joking manner, brought a gong to a staff meeting and rang it to get everyone’s attention when extraneous conversations got out of hand. Well, staff at one hospital didn’t laugh at the idea – they actually brought the gong into their OR’s! Brenckle and colleagues (Brenckle 2020) reported on how they used the gong to get everyone’s attention at the start of timeouts. They addressed the problem after a consultant noted, during a mock regulatory survey, that multiple members of the OR team were multitasking during the timeout and not paying sole attention to the timeout procedure.


They considered several sound-making devices to use in order to get the undivided attention of all OR staff at the onset of their timeouts. Ultimately, they chose a classic Tibetan gong. Despite some negative feedback and resistance early on, they persevered and incorporated the gong into their timeout routine.


It took almost six months before staff members began consistently using the gong properly. After piloting the gong in the cardiac cath lab, they also implemented it in their endoscopy suite and OR’s. After a year, they report no further negative feedback or improper use of the gong. Even physicians who originally refused to pause and engage in the timeout are now actively engaged in the process. One even not only engages in the timeout, but also personally strikes the gong at the end of his procedure to indicate it was successful.


Interesting and innovative! Timeouts are not to be taken lightly or in a joking fashion. But it is of utmost importance to get the attention of all the OR team (or the team in any venue performing procedures) to focus on the timeout. Whatever works best in your facility to accomplish that is worthwhile.




Some of our prior columns related to wrong-site surgery:


  September 23, 2008 Checklists and Wrong Site Surgery

  June 5, 2007              Patient Safety in Ambulatory Surgery

  July 2007                  Pennsylvania PSA: Preventing Wrong-Site Surgery

  March 11, 2008         Lessons from Ophthalmology

  July 1, 2008              WHO’s New Surgical Safety Checklist

  January 20, 2009       The WHO Surgical Safety Checklist Delivers the Outcomes  

  September 14, 2010 Wrong-Site Craniotomy: Lessons Learned

  November 25, 2008 Wrong-Site Neurosurgery

  January 19, 2010       Timeouts and Safe Surgery

  June 8, 2010              Surgical Safety Checklist for Cataract Surgery

  December 6, 2010     More Tips to Prevent Wrong-Site Surgery

  June 6, 2011              Timeouts Outside the OR

  August 2011             New Wrong-Site Surgery Resources

  December 2011         Novel Technique to Prevent Wrong Level Spine Surgery

  October 30, 2012      Surgical Scheduling Errors

  January 2013             How Frequent are Surgical Never Events?

  January 1, 2013         Don’t Throw Away Those View Boxes Yet

  August 27, 2013       Lessons on Wrong-Site Surgery

  September 10, 2013 Informed Consent and Wrong-Site Surgery

  July 2014                  Wrong-Sided Thoracenteses

  March 15, 2016         Dental Patient Safety

  May 17, 2016            Patient Safety Issues in Cataract Surgery

  July 19, 2016            Infants and Wrong Site Surgery

  September 13, 2016 Vanderbilt’s Electronic Procedural Timeout

  May 2017                  Another Success for the Safe Surgery Checklist

  May 2, 2017              Anatomy of a Wrong Procedure

  June 2017                  Another Way to Verify Checklist Compliance

  March 26, 2019         Patient Misidentification

  May 14, 2019            Wrong-Site Surgery and Difficult-to-Mark Sites


Some of our previous columns discussing video recording:


September 23, 2008 “Checklists and Wrong Site Surgery

December 6, 2010 “More Tips to Prevent Wrong-Site Surgery

November 2011 “Restricted Housestaff Work Hours and Patient Handoffs

March 2012 “Smile...You’re on Candid Camera!

August 27, 2013 “Lessons on Wrong-Site Surgery

March 17, 2015 “Distractions in the OR

November 24, 2015 “Door Opening and Foot Traffic in the OR

March 2019 “Another Use for Video Recording

March 17, 2020 “Video Recording in the OR






Freundlich RE, Bulka CM, Wanderer JP, et al. Prospective Investigation of the Operating Room Time-Out Process. Anesthesia & Analgesia 2020; 130(3): 725-729



Brenckle EA, Gealer D,  Milligan M. Using a Tibetan Gong to Increase Staff Member Engagement During Time Outs. AORN Journal 2020; 111(1): 81-86

(Brenckle 2020)






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