Surgical Site Signing and “Time Out”: Issues of Compliance or Complacence

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Background: Wrong-site surgery remains a common problem as voluntary preoperative skin-marking protocols have met only limited success. The purpose of the present study was to investigate orthopaedic surgeons with regard to their site-signing practices and “time out” procedural compliance for emergent and nonemergent surgical cases in a single health-care region before and after the institution of the “time out” protocol of the Joint Commission on Accreditation of Healthcare Organizations.

Methods: In the first study, performed in 2006, the presence of the initials of either the surgeon or the surgical resident in the draped surgical field was documented at the time of forty-eight procedures over a three-month period. In a second study, performed a year later, 231 randomly selected procedures were similarly evaluated, as was the performance of the newly adopted “time out” process.

Results: In the first study, after surgical field draping, the surgeon's initials were visible in 67% of emergent cases and 90% of elective cases. In the second study, the surgeon's initials were visible in 61% of emergent cases and 83% of elective cases. The “time out” was performed prior to the skin incision in 70% of the cases, was performed after the incision in 19%, and was not performed at all in 11%.

Conclusions: Orthopaedic surgeons should recognize the value of preoperative skin signing for all procedures and the additional value of the “time out” protocol. We recommend that surgeons strive for 100% compliance with both strategies.

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