Nearly every U.S. hospital uses surgical checklists to protect against mistakes in the OR.
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Published 2/1/2014
Jeffrey M. Nakano, MD

In Search of the Perfect Surgical Timeout

Are checklists a boon or boondoggle?

Orthopaedic surgeons who consider surgical checklist timeouts a boon to surgery probably don’t need to read any further. Those who view them as a boondoggle, however, should read on.

Surgical checklist timeouts have long been compared to seatbelts. Both can save lives, but when not used correctly, neither one works very well. The main difference between the two is that seatbelts are a lot easier to use properly and a bell sounds if the seatbelt is not used correctly.

As early as 2002, the AAOS took a leadership role in introducing surgical checklists as part of its “Sign Your Site” and “Patient Safety Is No Accident” campaigns. By 2007, the World Health Organization’s Safe Surgery Saves Lives program, under the leadership of Atul Gawande, MD, had developed a surgical checklist program that was piloted at eight sites around the world. Regardless of the country’s level of modernization or economic progress, the use of the checklist significantly reduced the number of deaths, surgical site infections, unplanned returns to surgery, and other complications. As a result, the surgical checklist has been adopted by hospitals around the world.

Today, nearly every U.S. hospital employs a surgical checklist and timeout to protect against mistakes in the operating room (OR). The following errors—estimated to occur as often as 80 times per week in the United States alone—are among those that can be avoided by using the checklist:

  • operating on the wrong patient or the wrong surgical site
  • performing the wrong procedure
  • leaving a retained foreign body
  • the death of an ASA Class 1 patient in the perioperative period

This list of so-called surgical “never events” was developed in 2002 by the National Quality Forum, a quasi-governmental consortium whose mission is to improve the quality of American healthcare.

Personal experience
My support of the checklist concept is based on personal experience as well as the literature. In 1995, I made an incision on the ring finger of a patient whose fracture was actually on the long finger. This past year, my son, who has a seizure disorder and requires a vagal nerve stimulator, was scheduled for a battery change. During the surgical checklist timeout, it was determined that someone had forgotten to order the replacement battery.

The literature also supports the need for surgical checklists. Two studies published in the past decade indicate that 21 percent of hand surgeons and 8 percent of knee arthroscopists report performing a wrong-site surgery during their careers.

However, I realize that not everyone embraces surgical checklists as I do. I once filmed surgical timeouts in preparation for a talk on surgical checklists that I presented at the Western Orthopaedic Association annual meeting. Despite six attempts over 2 days with different OR crews, I did not witness a single perfect timeout. As a result, I developed goals to strive for in each surgical case in which I participate. The following are what I consider the elements of a perfect surgical checklist timeout:

  • A fully engaged surgeon—The surgeon needs to be in the room during the timeout, particularly when the nurse identifies the patient, to ensure it is the correct patient. It’s also important to make sure that the studies on the screen are actually those of the patient.

Additionally, although the circulating nurse will typically lead the actual timeout, the surgeon has to be the one to make sure it is done correctly. If the nurse starts the timeout before everyone is paying full attention, the surgeon should encourage the circulator to stop until everyone is actually tuned in and attentive. If that means waiting for the anesthesiologist to get off the phone or the music to be silenced, so be it.

  • A set time for the timeout—The timeout should always be performed at the same point during the procedure. We typically do it immediately after the antimicrobial drape is stuck to the incision site. Using a consistent marker enables everyone make the most efficient use of their time prior to the timeout.
  • Easily seen checklists—A written checklist should be posted on the wall of the OR so that everyone can follow along to make sure that nothing is missed. If the nurse goes out of sequence, she or he should be stopped immediately so that the missed item can be addressed. (The surgeon needs to be engaged!)
  • A signed site—If the surgeon’s identifying initials are no longer visible at the surgical site, this should be acknowledged, and then it should be determined that the correct site is prepped.
  • A patient review—Any unusual aspects of the surgery should be mentioned by the surgeon, as well as the estimated blood loss. This would be the appropriate time to determine if a type and screen or type and cross is necessary and, if so, has been done.
  • An equipment review—Any unusual equipment needs should be addressed by the surgeon. My practice consists of mainly primary total joint arthroplasty, but I do some revisions. My hospital is somewhat isolated and if a particular piece of equipment is not on hand, it may be 4 hours or more before we can get the item. As a result, I prepare a comprehensive list of equipment needs that is provided to the OR a few days before the surgery. (This is another of the checklists I store on my computer).

Flying lessons
The aircraft industry is often given credit for perfecting the checklist idea. By the 1930s, aircraft had become so complicated that checklists were proposed to make flying more safe. Pilots, who realize that their lives—as well as the lives of their passengers—depend on a well-functioning aircraft, are very conscientious about using checklists. Can we as surgeons be any less careful?

Jeffrey M. Nakano, MD, is an orthopaedic surgeon in private practice in Grand Junction, Colo. He can be reached at

Editor’s Note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of David H. Sohn, JD, MD, ORM editor.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

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  2. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 2009 Jan 29;360(5):491-499. doi: 10.1056/NEJMsa0810119. Epub 2009 Jan 14.
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  4. McDaniel WJ, Albright DA: The incidence of wrong-site surgery in knee arthroscopy. J Bone Joint Surg Br 2005;87-B supp III:347.