Making the Surgical Safety Checklist Even Safer: A Team Timeout Checklist to Improve Information Exchange and...

The World Health Organization surgical safety checklist (WHO SSC) provides a standardized framework for preoperative safety procedures. However, studies have revealed substantial variation in adherence, with items being skipped or misunderstood and nurses likely to be less involved than other operating room (OR) professional groups. We introduce a 16-item team timeout checklist (TTOC) that clarifies and adds safety-critical items to the existing WHO before skin incision timeout and is led by nurses to improve information exchange, closed-loop communication, and encouraging participation of all professional groups.

Using a prospective pre-post interventional design, we live-coded all team communication during on-site observations in the OR focusing on the pre-incision phase. Surgical teams were first observed during a pre-intervention period without the TTOC checklist and subsequently during a post-intervention period after implementation of the TTOC checklist. The TTOC was evaluated on four communication outcomes critical for patient safety: information exchange of checklist items, measured as the percentage of the 16 items that were verbally communicated among team members (eg, team introduction, surgical site, allergies), participation rates of different professional groups, frequency of explicit coordination behaviors (eg, instruction, information request, speaking up) and the frequency of closed-loop communication sequences, defined as information request followed by information upon request within 30 seconds.

A total of 155 teams were observed, including 78 teams in the pre-intervention phase without TTOC use and 77 teams in the post-intervention phase using the TTOC, resulting in 13,127 coded communication events. The median information exchange increased from 62.5% (interquartile range [IQR] 50-68.8) in the pre-intervention phase to 100% (IQR 100-100) in the post-intervention phase (P < .001). For 15 of all 16 subitems, the odds of exchanging information were significantly higher after TTOC implementation than before TTOC implementation (odds ratios range 10.8-1896, all 95% confidence intervals [CIs] excluded 1). Participation rates increased for circulating nurses, scrub nurses, surgical residents, and anesthesia (all P < .05) but not for lead surgeons. Mean (standard deviation [SD]) closed-loop communication patterns per operation were more frequent with (20.4 [10.7]) than without the TTOC (16.4, [7.24]), P = .004.

In our study, the nurse-led TTOC significantly improved the exchange of safety-critical items during the pre-incision phase, facilitated closed-loop communication, and empowered the participation of various professional groups. These findings suggest integrating the TTOC with the WHO SSC before-incision protocol may have important advantages.