• Thomas J Caruso, Farrukh Munshey, Brea Aldorfer, and Paul J Sharek.
• Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, and Physician Lead, Perioperative Improvement Team, Stanford University School of Medicine, Stanford, California. Electronic address: tjcaruso@stanford.edu.
• Jt Comm J Qual Patient Saf. 2018 Sep 1; 44 (9): 552-556.

Problem DefinitionThe World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk.ApproachThe multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption.OutcomesIn seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice.Key InsightsAlthough initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.

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