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IMPROVING SAFETY AT WOODHULL:
TIME OUT
North Brooklyn Health NetworkWoodhull Medical Center
Edward Fishkin, MD, Medical Director, Principal InvestigatorMinda Aguhob, MEd, Time Out Program Director, Principal InvestigatorSaida Karimova, MD, Time Out Research Coordinator
Medical error is the THIRD leading
cause of death in the U.S.
To err is human.
Reducing error is good practice.
To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999
Reducing Error: Time Out Currently, a 16-item surgical safety checklist and a 6-
item medicine safety checklist at Woodhull Hospital
Confirms key patient and procedural data before performing a surgery or invasive procedure
Can make difference between life and death.
A multicountry WHO study in 2007-2008 + additional studies found that implementing a surgical safety checklist significantly reduced complications and deaths associated with surgery.
WHO publication
2006 2009
NY DOHRecommendations*
Joint CommissionUniversal Protocol
2010*Woodhull adopted Time Out in 2006.
Checklist Studies: ResultsDeath Rate Reduced by Half
WHO 2009: Cut nearly in half, from 1.5% to 0.8% (significant; p=0.003) Weiser 2010: Cut by more than half, from 3.7% to 1.4% (significant;
p=0.0067)
Inpatient Complications Reduced by Over One Third WHO 2009: Cut by over one third, from 11.0% to 7.0% (significant;
p<0.001) Weiser 2010: Cut by over one third, from 18.4% to 11.7% (significant;
p=0.0001)
Haynes, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360;5:491-9
Weiser TG, et al. Effect of a 19-item surgical safety checklist upon urgent operations in a global patient population. Annals of Surgery 251;5:976-980 May 2010
Who is involved in a Time Out?
Clinical staff involved in the procedure are required to participate in the Time Out: Attending Physicians Residents Nurses Physician Assistants
VIDEO OF TIME OUT PROCEDURE
What is on the Time Out checklist?
Confirm:Step 1 – Correct patient using 2 identifiersStep 2 – Correct procedureStep 3 – Correct patient positionStep 4 – Correct site is markedStep 5 – Essential imaging is displayed. Step 6 – Availability of all necessary equipment
What procedures require Time Out?
Any procedure that requires informed consent form.
For example: Central line placement
Nationwide, hospitals cut the infection rate by nearly 60% between 2001 and 2009, preventing 25,000 bloodstream infections the CDC estimates, using CLABSI checklist (which includes Time Out) in March 4, 2011 Morbidity and Mortality Weekly Report
Paracentesis Lumbar Puncture Etc.
Time Out Project: TimelineJuly 2011 – Dec 2011
IRB approval
Time Out Project informational sessions for staff
Collection of consent forms
Alliance with Residents (House Staff Safety Council)• A resident-driven committee whose purpose is to promote a
culture of house staff participation in improving patient care and safety
• Prioritizes and drives safety initiatives.• Resident on research team
Alliance with Nursing
Time Out ProjectNov 2011 to Sept 2012
Conducted Wave 1 Time Out direct and video observations
• Actual Time Out was videotaped• Survey was conducted to capture staff attitudes,
opinions and ideas on Time Out, safety, and team communication
Oct 2012 – March 2013 Conduct Wave 2 Time Out observations with
training program• Random training: Video or simulation• Actual Time Out to be videotaped
Results: Jan 2011-Sept 2012
Table reads: The number of Time Out items checked in the OR, and in Medicine (ICU, GI Clinic, ED, Floor), as recorded on written (live) observation.
Results: Jan 2011-Sept 2012
Table reads: The number of Time Out items checked in Medicine (ICU, GI Clinic, ED, Floor), recorded with both written (live) observation, and on video observation.
Research Questions
1. How well is Time Out being performed, according to the predetermined criteria?
2. Do videotaped rehearsals of Time Out, or showing a video of an “Ideal Time Out,” have an impact on the quality of Time Out performance? If so, is one method preferable?
3. What are the staff’s attitudes and opinions on Time Out, ideas for improving safety, and perception of team communication? Do any of these correlate to Time Out performance?
4. Is there a significant difference in accuracy among the various methods for evaluating Time Out performance (video observations, direct observations, or self-report)?
Goal: Change in Habits of Thinking
From “Another task I have to do"
to “This will help me make my care safer."
It's a sea change.
E. Fishkin, email communication, 8/23/10
Bibliography Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H., Dellinger, E. P.,
. . .Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360, 491–499.
Weiser TG, et al. (2010). Effect of a 19-item surgical safety checklist upon urgent operations in a
global patient population. Annals of Surgery, 251(5), 976-980.
Contact InfoQuestions about Time Out Project:Edward Fishkin, [email protected]
Minda Aguhob, [email protected]
Saida Karimova, [email protected]
Learn more at Minda’s blog: http://educationhealthcarereform.wordpress.comTwitter: @Studentsforqual
Institute for Healthcare Improvement (IHI), American College of Medical Quality (ACMA) and American Medical Student Association (AMSA) are supporters of the Time Out Project.
Time Out Training Video – HHCNYC YouTube* -
*Developed by Edward Fishkin, Minda Aguhob, Saida Karimova, and Jonathan Ehinger. Soon to come on NYC HHC Intranet. Time Out Training Video for medicine to come, Nov 2012.
