Patient Safety Tip of the Week

September 13, 2016

Vanderbilt’s Electronic Procedural Timeout



Checklists are marvelous tools to ensure completion of important tasks and improve quality and patient safety. But use of some checklists has not yet met with universal acceptance (see, for example, our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” and our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists”).


Recently, Singer and colleagues did direct observation of over 200 surgical procedures at 10 South Carolina hospitals to evaluate checklist performance and surgeon buy-in (Singer 2016). Few teams completed most or all SSC items and teams more often completed items considered procedural “checks” than conversation “prompts.” In fact, in only 3% of cases was there full completion of checklists. Clinical leadership, communication, a summary measure of teamwork overall, and observers’ teamwork ratings positively related to overall checklist completion. Age of the patient and case duration also correlated with completion of more checklist items. Though shared clinical leadership, open communication, active coordination, and mutual respect were critical in prompting case-related conversations, they did not result in completing more procedural checks.


One of the most important uses of checklists in healthcare, of course, is that used for the surgical or procedural timeout. We use that to help verify we have the correct patient, are going to do the correct procedure, and do it on the correct side or site. Despite a focus on avoiding never events over the past 2 decades, cases of wrong patient, wrong site, wrong side surgery/procedures continue to occur. Universal Protocol and the surgical timeout in theory should prevent most such incidents. However, actual compliance with these is often suboptimal. We’ve previously discussed many of the issues in inadequate timeouts: failure to include all participants, failure to get “active” participation of members, failure to have all participants devote their sole attention to the timeout procedure, failure to consult primary documents, checkboxes for items not done checked as complete, checkboxes/documentation completed after the case, skipped items, poor patient safety culture, and many others.


Education and training have limited ability to improve compliance with the surgical/procedural timeout. We’ve been big fans of using forcing functions or constraints to improve compliance. Such interventions include things like preventing opening of the surgical trays or procedure kits until all the items on a timeout checklist have been completed.


Vanderbilt University Medical Center took a similar approach, with a unique twist, to improving their surgical/procedural timeouts – they created an electronic version of the timeout in which all steps need to be completed before a case can proceed (Rothman 2016). Basically, all their OR’s are equipped with large LCD screens that are the equivalent of electronic “white boards”. Their proprietary software system makes available all relevant clinical and administrative information. Projected on the displays before an incision is made is their item-by-item surgical/procedural timeout. Their process is a forcing function in that documentation of the case cannot proceed until all items have been checked off as completed. The system currently has 13 questions but an abbreviated 3-question timeout is used for emergency cases.


Since implementation they have essentially had 100% compliance with timeouts and they have had no cases of wrong surgery. Given the rarity of wrong surgery overall, one cannot state with certainty that the system has prevented wrong surgery but this is a very sound system. It apparently has been well accepted and has been sustainable. It has been both time- and cost-efficient to implement.


Take time to read the Rothman article, which has samples of the displays used in their system. It looks easier than paper-based checklists and is something most hospitals and ambulatory surgery centers could easily implement.


In our many columns on use of checklists in healthcare (and other industries) we’ve emphasized a number of factors that are important for promoting their use. We’ve discussed in detail in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” and our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists” some factors that may contribute to a trend toward checklist fatigue. First and foremost is buy-in from those who will be using the checklists as tools. And buy-in requires that there be an appropriate culture of patient safety.


NASA (NASA 2014), which oversees the ASRS (Aviation Safety Reporting System) has noted that reports submitted to ASRS indicate that errors related to checklist usage generally fall into one of these five categories:

  1. Checklist interrupted
  2. Checklist item overlooked
  3. Use of the wrong checklist
  4. Failure to use a checklist
  5. Checklist confusion


NASA also in a subsequent newsletter (NASA 2015) noted 5 important factors in appropriate use of checklists:

  1. Remember to Use It
  2. Check Every Item, Every Time
  3. Slow Down; Confirm Critical Items
  4. Read It Correctly
  5. If Interrupted, Restart from the Beginning


Note also we have in several previous columns noted a guidance from the UK Civil Aviation Authority that has some excellent recommendations about the design of emergency checklists used in aviation (UK Civil Aviation Authority 2006). Many of these design issues are equally applicable to healthcare checklists.


In our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists” we noted a study by Russ and colleagues (Russ 2015) that offered the following lessons for implementing change:


We hope that you will go back and read our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists”. In particular, pay attention to the interesting perspective by Eliot Grigg (Grigg 2015) on improving use of checklists and avoiding checklist fatigue and using technological capabilities to make the checklists more useable. While Grigg’s focus was on anesthesia-related checklists, we gave an example of how we could apply many of his principles to other healthcare checklists.


And, speaking about checklists, The Joint Commission has just put out “The Joint Commission Big Book of Checklists”. It contains lots of downloadable checklists for a variety of purposes and which you can customize for your own use.




Some of our prior columns on checklists:



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”

  May 17, 2016            “Patient Safety Issues in Cataract Surgery”

  July 19, 2016             “Infants and Wrong Site Surgery”






Singer SJ, Molina G, Li Z, et al. Relationship between operating room teamwork, contextual factors, and safety checklist performance. J Am Coll Surg 2016; Jul 25, 2016 [Epub ahead of print]



Rothman BS, Shotwell MS, Beebe R, et al. Electronically Mediated Time-out Initiative to Reduce the Incidence of Wrong Surgery: An Interventional Observational Study. Anesthesiology 2016; 125(3): 484-494



NASA. Checklist Checkup. Callback 2014; 410: 1-2 March 2014



NASA. A Checklist Checklist. Callback 2015; 428: 1-2 September 2015



Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use

of Emergency and Abnormal Checklists. 2006.



Russ SJ, Sevdalis N, Moorthy K, et al. A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project”. Annals of Surgery 2015; 261(1): 81-91



Grigg E. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg 215; 121(2): 57-573



TJC (The Joint Commission). The Joint Commission Big Book of Checklists. 2016






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