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Prospective Investigation of the Operating Room Time-Out Process

Freundlich, Robert E., MD, MS*,†; Bulka, Catherine M., PhD; Wanderer, Jonathan P., MD, MPhil*,†; Rothman, Brian S., MD*,†; Sandberg, Warren S., MD, PhD*,†,§; Ehrenfeld, Jesse M., MD, MPH*,†,§,‖

doi: 10.1213/ANE.0000000000004126
Patient Safety: PDF Only

BACKGROUND: Although the surgical pause or time-out is a required part of most hospitals’ standard operating procedures, little is known about the quality of execution of the time-out in routine clinical practice. An interactive electronic time-out was implemented to increase surgical team compliance with the time-out procedure and to improve communication among team members in the operating room. We sought to identify nonroutine events that occur during the time-out procedure in the operating room, including distractions and interruptions, deviations from protocol, and the problem-solving strategies used by operating room team members to mitigate them.

METHODS: Direct observations of surgical time-outs were performed on 166 nonemergent surgeries in 2016. For each time-out, the observers recorded compliance with each step, any nonroutine events that may have occurred, and whether any operating room team members were distracted.

RESULTS: The time-out procedure was performed before the first incision in 100% of cases. An announcement was made to indicate the start of the time-out procedure in 163 of 166 observed surgeries. Most observed time-outs were completed in <1 minute. Most time-outs were completed without interruption (92.8%). The most common reason for an interruption was to verify patient information. Ten time-out procedures were stopped due to a safety concern. At least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures observed.

CONCLUSIONS: Compliance with preincision time-outs is high at our institution, and nonroutine events are a rare occurrence. It is common for ≥1 member of the operating room team to be actively distracted during time-out procedures, even though most time-outs are completed in under 1 minute. Despite distractions, there were no wrong-site or wrong-person surgeries reported at our hospital during the study period. We conclude that the simple act of performing a preprocedure checklist may be completed quickly, but that distractions are common.

From the Departments of *Anesthesiology

Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee

Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois; and Departments of


Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.

Accepted for publication February 7, 2019.

Funding: This work was supported by the Department of Anesthesiology. R.E.F. received support from the National Institutes of Health–National Center for Advancing Translational Sciences (1KL2TR002245) and received grant support and consulting fees from Medtronic for work unrelated to the content of this manuscript.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Institutional review board: Vanderbilt University Human Research Protection Program, Linda Gooch, Administrative Assistant, 1211 Medical Center Dr, Nashville, TN 37212. E-mail:

Reprints will not be available from the authors.

Address correspondence to Robert E. Freundlich, MD, MS, Department of Anesthesiology, Vanderbilt University Medical Center,, 1211 21st Ave S, MAB 422F,, Nashville, TN 37212. Address e-mail to

© 2019 International Anesthesia Research Society
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