The day he made the mistake, the surgeon at Regions Hospital jumped the gun. ¶ He was supposed to wait for the "timeout," when everyone in the operating room pauses to make sure that the right patient is getting the right operation.
But in December 2007, the surgeon skipped that step, picked up the scalpel and made the first incision -- in the wrong spot.
The patient wasn't seriously harmed, said Dana Langness, senior director of surgical services at Regions in St. Paul. But for Langness, it was another frustrating reminder of how easily patients can slip through the safety net inside the operating room and grave medical errors can occur.
In the past few years, Regions and other hospitals have piled on new safety rules in a growing effort to prevent surgical errors. But they've found, to their dismay, that people keep making the same mistakes in spite of them.
Since 2003, 150 surgical mix-ups have been reported throughout Minnesota, including 97 operations on the wrong body part and nine on the wrong patient, according to a Jan. 16 report from the state health department. Although rare, these headline-grabbing episodes are just a slice of a broader problem of hospital medical errors that affect thousands of patients nationally every year.
As a result, hospital officials are experimenting with new ways to prevent mistakes. One of them is as simple as a cloth.
Last year, after the operating-room blunder, staffers at Regions designed what they call a "timeout towel" to cover surgical instruments before operations. Now any surgeon who reaches for the scalpel too soon -- before the safety rituals are complete -- is greeted with the words "Time-Out!" emblazoned in red.
It might seem like a small thing. But at Regions and elsewhere, experts in patient safety have found that it's not enough to put new rules in place. They have to make sure that people under pressure pay attention to them. That often involves changing deeply embedded habits -- and that's been a lot tougher than expected.
"People are always surprised," said Langness. But distractions can derail even the most skilled and conscientious among them, she said.
Last year, researchers from the University of Minnesota got a rare glimpse of what can go wrong inside the operating room. They observed more than 50 operations at eight Minnesota hospitals to study the "timeout" ritual, which is widely used as a safeguard against surgical mix-ups.
They found that, "in most cases," staffers simply ignored the timeout or went about their work, rendering the exercise virtually meaningless, according to a 2008 report from the university's Center for Design in Health. "I think there was an underlying assumption that it was functioning just fine," said Kathleen Harder, the center's director, who led the study with a colleague. "But it was not effective."
In theory, the "timeout" was designed to give everyone in the room a chance to speak up if he or she suspects something's wrong. Just before the operation, someone (often a nurse) announces the timeout, reads aloud the patient's name and details of the procedure, and checks to make sure that the surgeon has marked the proper site (if it's a knee or elbow, for example). Although patients might wonder how such crucial details can possibly get mixed up, it can be easy to lose track when a surgical team performs dozens of similar procedures in a week.
Safety net riddled with flaws
In practice, the timeout often didn't work as planned, Harder found. "In most cases, the team continued to work during the Time Out," she reported in her study, which was funded by the Minnesota Department of Health. "In several cases, the circulating nurse attempted to call the Time Out but failed because others continued to talk or did not stop their activities." In one case, the surgeon wasn't even in the room at the time. In others, a nurse would recite the details from memory, without checking records.
"There's this idea out there, that I'm doing my best to refute, that multitasking in complex systems is something we can do," said Harder. "It simply isn't the case."
The result, she found, was a safety net riddled with flaws.
Among the solutions they suggested: A timeout towel.
It's what Harder calls a "memory trigger."
"It signals to the surgeon that this is something they need to do," she said. At the same time, she has called for major changes to ensure that everyone plays an active role in safety rituals.
At Regions, some of those changes went into effect this month. From now on, Langness said, surgeons, nurses and technicians will all have a detailed script to follow to make sure they cover all the bases before the first incision is made.
The towel, meanwhile, may be catching on around the country. A California company, Sandel Medical Industries, started selling its own trademarked version -- a bright orange "Time Out Beacon" -- last May. Today, the company calls it "one of our top-selling safety products."
For Harder, that's encouraging news. But "it's not going to solve everything," she adds, "The timeout towel doesn't have arms and it doesn't have a mouth. It's not going to say 'Stop.' ...
"If they do the timeout in a really sloppy manner," she said, "errors can still occur."
Maura Lerner • 612-673-7384
