The Surgical Timeout - Stanford Hospital & Clinics

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Understanding Adverse Events Conditions: Unfamiliarity with task Time shortage Poor signal to noise ratio Information overload Inexperience Poor instructions or procedures Inadequate checking Educational mismatch of person & task Disturbed sleep patterns Hostile environment Boredom Risk factor: fold 17 11 10 Unfamiliarity with task Poor human/system interface 8 6 3 3 3 2 1.6 1.2 1.1
Current medical practices • Quality care comes from excellent training • Mistakes are personal failures • BUT • limitations of memory, stress, fatigue, distractions, interruptions and limited multi‐ tasking skills • MISTAKES
Page 1 and 2: The Surgical Timeout Mark Lane Welt
Page 3: Why (not?) • “Let me just do it
Page 7 and 8: Leonard, M et al. Qual Saf Health C
Page 9 and 10: Assertion cycle. This is a model to
Page 11 and 12: Common critical language • Hierar
Page 13 and 14: Understanding Adverse Events Unfami
Page 15 and 16: Check list reduction in M&M • Mor
Page 17 and 18: • Patient confirms “Sign in”
Page 19 and 20: “Sign out” • Nurse verbally c
Page 22 and 23: Stanford WHO Checklist Experience M
Page 24 and 25: Stanford WHO Checklist Experience U
Page 26 and 27: Stanford WHO Checklist Experience S

The Surgical Timeout - Stanford Hospital & Clinics

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