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A Superb Idea for Nixing OR Errors

It is not often that an aficionado of the ambulatory s.c. applauds the activities at the local community hosp., but right now is just that moment. A bit of background should be, perhaps, shared with the reader before diving into the details.

I leave the comfort of my own facility every few weeks to venture upstate to the most excellent Landmark Medical Center that is, despite its large name, a very friendly and comfortable small town hospital. It belongs to HARI, the Hospital Association of Rhode Island to which also belong the major teaching hospitals of our capital, one of which is recovering from a bit of clumsiness involving not only wrong site surgery, but also wrong patient surgery.

If we were a group of flies on the wall at a recent HARI meeting we would no doubt have heard a discussion about how to avoid such distasteful surgical errors. No doubt further we would have heard passionate discussion focusing on the usual alternatives, labels, markers, signs, shaves, perhaps even ribbons and bells. We would have, then, been collectively and pleasantly surprised to hear, "Why don't we just introduce the patient to the surgical team?"

And so it began. "Time Out" is now used in all of Rhode Island's hospitals. Whilst the surgical team is setting up for Dr. Able's knee or Dr. Baker's ear, or whatever surgeon and whichever organ was the expected project, the patient is wheeled into the operating room. If we flies were allowed into the operating room we would hear the wheeling nurse, looking at the consent paperwork, announce to the team, "This is Mrs. Jane Doe and she's here to have a cataract operation on her right eye." The members of the surgical t. offer a "Good morning, Mrs. Doe," and return to work.

In a flash moment the next liver or spleen becomes a neighbor and friend. The anonymous clogged artery or varicose vein becomes my school chum's aunt and her arterial bypass a detour I want to help construct. The hangnail on the right big toe means we should avoid prepping the left baby finger. Meanwhile Mrs. Doe is beginning to relax knowing we don't think she's Mr. Jones with the hernia.

Time Out forces the entire team to hold on there just a minute, stranger, and notice if things are quiet, too quiet. The quick pop from assembly line to personal attention is such an improvement that it makes me think that I should go ahead and get my right kidney fixed, now that I know they won't confuse it with Mrs. Smith's ovaries.