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Minnesota Safe Surgery Coalition. Coalition Goal: Eliminate Wrong Site, Wrong Procedure and Wrong Patient Events within 3 Years . Members Minnesota Hospital Association Minnesota Department of Health Minnesota Medical Association Minnesota Medical Group Management Association MMIC Group.

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minnesota safe surgery coalition
Minnesota Safe Surgery Coalition
  • Coalition Goal: Eliminate Wrong Site, Wrong Procedure and Wrong Patient Events within 3 Years.
  • Members
    • Minnesota Hospital Association
    • Minnesota Department of Health
    • Minnesota Medical Association
    • Minnesota Medical Group Management Association
    • MMIC Group
the minnesota time out campaign
The Minnesota Time Out Campaign
  • Phase 1 of the Safe Surgery Project
  • Targets Wrong Site Events
    • Objective: Administration, physicians and front-line staff will join together to hold each other accountable for conducting robust, effective Time Outs for every patient, every invasive procedure, every time.
  • Kick-off on National Time Out Day (June 15)
why is the campaign necessary
Why is the Campaign Necessary?

Reports of adverse events involving procedures performed on the wrong site/side/level have been increasing in Minnesota.

Last year, 66% of wrong site procedures were on the wrong side (right vs. left).

sample minnesota events
Sample Minnesota Events

The Anesthesia Care Provider inserted the needle to perform an anesthesia block.  The patient felt a twitch in their leg and stated that the twitch was on the left side and the surgery should be on the right side. The patient was correct.

No site marking or Time Out had been performed for the block.

Site mark for right stent placement placed on arm and was not visible after prepping and draping. Left stent placement performed.

Site mark was not visualized during the Time Out.

sample minnesota events1
Sample Minnesota Events

Surgeon consulted on patients in two different rooms. Surgeon performed knee aspiration on incorrect side thinking it was the other patient.

Patient identity was not verified and Time Out was not performed.

Patient consented to left knee arthroscopy. Right leg placed in holder and tourniquet placed.  Surgical site had been marked but when initials were not seen on the right leg surgeon thought marked was removed by surgical prep. 

Site marked was not visualized during the Time Out.

sample minnesota events2
Sample Minnesota Events

Patient consent for a right knee arthroscopy. All documents indicated right knee and right knee was site marked by surgeon. Surgeon and nurse put leg holder on left side of table and positioned left leg in holder.  Left knee injected, prepped and draped.  Time Out conducted and incision made to left knee.  When nurse started documentation, she noted that the left knee was intended and informed the surgeon.  

Site mark was not visualized during the Time Out. All members of the team were not engaged in the Time Out process.

why focus on time out
Why Focus on Time-Out?
  • Almost all of the 2010 wrong site procedures in Minnesota were breakdowns in basic best practices - primarily in the Time Out process.
  • Observational studies of time out in Minnesota ORs show that:
      • Site mark not visualized
      • Source documents not referenced
      • Stating “I agree” rather than independent verification
      • In a number of instances, such as an anesthesia block prior to a surgical procedure, there was no process in place to conduct site marking and a Time Out.
development of mn time out
Development of MN Time Out

Developed by University of MN Center for Human Factors Research and Design

Observed 58 procedures across 8 hospitals

Direct observations

Focus groups

addressing gaps
Addressing Gaps
  • MN Time Out addresses observed gaps
    • Uncertainty about initiation
    • No cessation of activity
    • No acknowledgement of accuracy of information
    • No referral to source documents
    • No or incorrect site marks
    • Team members not cognitively engaged
call to action for physicians
Call to Action for Physicians

All steps of the Time Out must be conducted before every invasive procedure for every patient, every time.

Key areas where a Time Out is not consistently applied across the state:

OR procedures

Blocks and injections prior to OR procedures

Stand alone anesthesia blocks

Interventional radiology procedures

stop the line practice
Stop the Line Practice

Any person who observes or becomes aware of harmful situation in patient care has the authority and responsibility to speak up and request the process be stopped in order to clarify the patient safety situation.

This person needs to say in a firm, clear and respectful manner: “STOP, I have a patient safety concern.”

Staff are to assertively voice concern at least two times to ensure the request has been heard.

If there is noncompliance to respond to this time out, the Chain of Command process is invoked.

success stories
Success stories

An elderly patient undergoing repair of a hip fracture was prepped for a right-sided procedure, consistent with the consent, history and physical, and a consultation report. During the time out, the surgical team determined that the patient had a left hip fracture, which was then confirmed by x-ray. The procedure was performed on the correct side.

Wrong knee was marked in pre-procedure area. Verification of the site marking against source documents uncovered the discrepancy and correct site was marked and surgery completed.

take home points
Take-Home Points

A Time Out must be completed prior to any invasive procedure across the organization for every patient, every time.

All Time Outs must be completed following the 5 key steps in the Time Out process.

If there are any discrepancies during the Time Out or a step is not completed, members of the team will “Stop the Line” until resolution and agreement by the team.

Staff and physicians will be supported by administration in “Stopping the Line.”