How diminishing returns may render the surgical timeout ineffective


Wrong site surgery is never acceptable.  A surgeon ought never to find himself in a situation where he has to inform the family that he just operated on the wrong body part.  It is embarrassing, unprofessional, and an egregious violation of the patient/physician covenant.

That being said, we have allowed this issue to be defined entirely in terms of “systems management”.  And hence the rise of the timeout and the checklist.  The ultimate responsibility for identifying the proper surgical site has been diluted.  No longer is it at the sole discretion of the operating surgeon.  Now we have a team-based approach involving nurses, anesthesia personnel, mid level providers, and surgeons.   Performance of a group timeout (of which I am actually a strong proponent) has quickly become the standard of care at most American hospitals prior to initial incision.

But the bureaucrats have taken a good idea and muddled it up in layers of unnecessary complexity.  The simple timeout has been expanded and diversified.  Now, for a routine elective surgery I am required to see the patient in the holding area for proper marking of the site (as applicable), to sign the H&P, and answer any questions the patient may have.  This is a standard protocol.  I have been doing exactly this same thing since I was a resident.

The next layer of the process occurs when the patient arrives in the OR.  This is called the “sign in”.  At this point we confirm that we have the right patient and are proposing to do the proper procedure.  Once the patient is asleep we then perform the official timeout, which involves repeating the same facts already addressed at steps one and two.  Finally, once I have scrubbed in and am ready to commence the case, we have to all participate in the pause.  In the pause, I am supposed to repeat the same mindless data as in steps 1,2,and 3.   Then, and only then, am I allowed to take the scalpel and begin.

On the surface, the casual reader may be thinking to herself, “well if it improves patient safety, what’s the big deal?  You doctors are so arrogant.”  To that I would respond, “then why don’t we make even more layers of screenings?  If four steps are better than one, then why shouldn’t we be taking 8 or 10 mini-pauses prior to starting these cases?”

Why don’t we take a pause before I move on from one step of a gallbladder removal to the next?  Why don’t we make checklists for “when it’s safe to put a clip on the cystic duct?”  The truth is that once you state the pertinent facts of an case , i.e. patient name, procedure, which side, proper antibiotic, etc, each subsequent oration of said facts devolves ever more obscurely into rote recitation, mumbled and mindless.  The fourth time we state the patient’s name and procedure, no one is paying any attention.  Every one’s guard is down.  We are fogged by a sense of false security.  We did our timeout!  Now it’s impossible something bad could occur!

No one seems to have considered the concept of the law of diminishing returns.  Repetition is sometimes harmful.  The surgeon may have marked the patient improperly to begin with.  I don’t care if the team repeats the mindless mantra 50 times. If the initial evaluation was performed incorrectly, all the timeouts and pauses and huddles in the world will fail to salvage the patient from harm.

My primary problem with the whole overly complicated, multi-tasked process is that it disperses ultimate responsibility from individuals and focuses too much on broad, systemic solutions.  For wrong site surgery, the ultimate responsibility lies with one person: the operating surgeon.  If he is so lackadaisical and irresponsible to the extent that he needs a team-based, multi-layered algorithmic approach to preventing wrong site surgeries, then he really has no business ever drawing a knife again.

It’s about professional duty.  A surgeon who doesn’t review his notes, who doesn’t re-examine the patient in the holding area and mark the proper side himself, is a surgeon who is on the road to having his privileges permanently revoked.  Exempting surgeons from the consequences of unprofessional, negligent conduct only obscures the root cause of  the problem.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

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