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International Forum on Quality and Safety in Health Care, March 2009, Berlin, Germany

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1E. N. de Vries, 2S. M. Smorenburg, 3W. S. Schlack, 1D. J. Gouma, 1M. A. Boermeester. 1Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; 2Department of Patient Safety, Academic Medical Center, Amsterdam, The Netherlands; 3Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands

Background: A recent systematic review showed that over 50% of in-hospital adverse events are related to a surgical procedure. In a tertiary referral centre, a surgical safety checklist monitoring critical safety risks and information transfers during the entire surgical pathway was developed. As the first part of the step-by-step implementation of this so-called SURPASS checklist, a time out (TO) procedure was implemented. The TO was to be performed in the operating room before start of induction. The operating room assistant was to register all items of the TO, as well as intercepted incidents, in the electronic registration system already in use in the operating room.

Methods: The TO was implemented in all surgical specialties. Monthly feedback was provided to all involved personnel. All electronically self-registered intercepted incidents were extracted and analysed monthly. In addition, a sample of procedures was observed by an independent researcher to validate the data obtained by self-registration.

Results: TO compliance was high: overall performance rose from 76% in the first month to 89% in the final month. The TO intercepted many incidents: during 8923 performed TOs, 976 intercepted incidents (10.9%) were registered, among which were 21 wrong-side incidents. During the validation study, a sample of 250 procedures was observed. Of 25 observed incidents, only 9 were registered in the electronic system, implying the data from this system represent an underestimation of the number of incidents.

Conclusion: A TO procedure was successfully implemented into daily practice. Compliance was high and the TO intercepted many near-incidents, …

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