Let's see how a well-known surgeon answers that question.
This Boston surgeon performed the wrong procedure on the hand of an elderly woman and then disclosed the excruciating details of his error in one of the nation's most prominent medical journals.
As usual, this case had all of the classic error-inducing factors:
The procedure was done at the end of a long day;
Stress was high because several other surgeons were behind schedule. When surgeons are stressed, the surgical team is stressed;
The patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment;
The surgeon didn't have a habit of leading or actively participating in the Time Out (seeing them as an unnecessary burden);
There were communication issues as the patient didn't speak English.
The surgeon spoke Spanish and conversed with his patient in that language. This exchange in Spanish was mistakenly interpreted by the Circulator as a “Time Out,” but no formal process was conducted in English.
While admittedly I wasn't there for this event, I have personally observed many other OR situations like this one, and conducted or reviewed the root cause analysis of hundreds of similar events. Based on that experience, I have no doubt that the nurse had an internal debate with herself about whether she should speak up and make an assertive statement about the Time Out and the need to do it in English for the benefit of the team.
For whatever reasons, including the stress she felt from the surgeon who had let it be known he thought the Time Out was a waste of time, and the fact that the surgeon didn't typically lead, or get actively involved in the Time Out, she decided it was okay to let it slide.
What would have made it easier for the Circulator to speak up and help change the outcome here?
If the surgeon had always made it a habit of effectively leading the Time Out as if he believed doing so was the hallmark of a healthcare professional, the Circulator would have instantly known something was amiss when it didn't happen for this case. It would be unthinkable for a professional airline Captain or an experienced private pilot to not conduct a pre-takeoff checklist, but not unthinkable for this surgeon to forego a Time Out.
Even though I no longer fly big jets for the airlines, I still would never get airborne in my high-performance private airplane without investing a few moments in completing my pre-takeoff checklist. Conducting that checklist is part of my DNA as an aviation professional. To not conduct it would be a self-inflicted wound on my professional identity. Anyone flying with me would instantly know something was out of order if I didn't use the checklist.
Second, if the surgeon was in the habit at the beginning of his procedures of making a "safety statement" - explicitly encouraging his team to speak up if they saw something not in the patient's best interest - it would have made it easier for the nurse to speak up.
You'll never get on an airliner in the U.S. where the Captain hasn't made a safety statement like this to their crew. Asking for a crosscheck is, again, part of our professional DNA. Even as a private pilot, I encourage anyone flying with me to speak up about anything that causes them concern.
Either of these two things by the surgeon - a disciplined use of the Time Out and/or an explicit request for speaking up - would have enabled the Circulator to intervene.
A classic, effective, stop-the-line assertive statement by the circulating nurse at that moment she realized a Time Out had not been conducted in English would have changed everything.
But, that's not what happened.
The result was the surgeon performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.
What did the surgeon learn? “I no longer see these protocols (the Time Out) as a burden. That is the lesson,” he said.
Unfortunately, so many people see the proper execution of a Time Out as an unnecessary time-waster until "the unthinkable" happens to them.
Experience is a great teacher, but she sends in terrific bills.
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