1. North Brooklyn Health Network
Woodhull Medical Center
Edward Fishkin, MD, Medical Director, Principal Investigator
MindaAguhob, MEd, Time Out Program Director, Principal Investigator
SaidaKarimova, MD, Time Out Research Coordinator

2.  Medical error is the THIRD leading
cause of death in the U.S.
 To err is human.
 Reducing error is good practice.
To Err Is Human: Building a Safer Health System.
Washington, DC: Institute of Medicine; 1999

3.  Currently, a 16-item surgical safety checklist and a 6-item medicine
safety checklist at Woodhull Hospital
 Confirms key patient and procedural data before performing a surgery
or invasive procedure
 Can make difference between life and death.
 A multicountry WHO study in 2007-2008 + additional studies found
that implementing a surgical safety checklist significantly reduced
complications and deaths associated with surgery.
NY DOH Joint Commission
WHO publication
Recommendations* Universal Protocol
2006 2009 2010
*Woodhull adopted Time Out in 2006.

4. Death Rate Reduced by Half
 WHO 2009: Cut nearly in half, from 1.5% to 0.8% (significant; p=0.003)
 Weiser 2010: Cut by more than half, from 3.7% to 1.4% (significant; p=0.0067)
Inpatient Complications Reduced by Over One Third
 WHO 2009: Cut by over one third, from 11.0% to 7.0% (significant; p<0.001)
 Weiser 2010: Cut by over one third, from 18.4% to 11.7% (significant;
p=0.0001)
Haynes, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med
360;5:491-9
Weiser TG, et al. Effect of a 19-item surgical safety checklist upon urgent operations in a global patient
population. Annals of Surgery 251;5:976-980 May 2010

5. Clinical staff involved in the procedure are
required to participate in the Time Out:
 Attending Physicians
 Residents
 Nurses
 Physician Assistants

7. Confirm:
Step 1 – Correct patient using 2 identifiers
Step 2 – Correct procedure
Step 3 – Correct patient position
Step 4 – Correct site is marked
Step 5 – Essential imaging is displayed.
Step 6 – Availability of all necessary equipment

8. Any procedure that requires informed consent form.
For example:
 Central line placement
Nationwide, hospitals cut the infection rate by nearly 60%
between 2001 and 2009, preventing 25,000 bloodstream
infections the CDC estimates, using CLABSI checklist (which
includes Time Out) in March 4, 2011 Morbidity and Mortality
Weekly Report
 Paracentesis
 Lumbar Puncture
 Etc.

9. July 2011 – Dec 2011
 IRB approval
 Time Out Project informational sessions for staff
 Collection of consent forms
 Alliance with Residents (House Staff Safety Council)
• A resident-driven committee whose purpose is to promote a culture
of house staff participation in improving patient care and safety
• Prioritizes and drives safety initiatives.
• Resident on research team
 Alliance with Nursing

10. Nov 2011 to Sept 2012
 Conducted Wave 1 Time Out direct and video
observations
• Actual Time Out was videotaped
• Survey was conducted to capture staff attitudes, opinions
and ideas on Time Out, safety, and team communication
Oct 2012 – March 2013
 Conduct Wave 2 Time Out observations with training
program
• Random training: Video or simulation
• Actual Time Out to be videotaped

11. Table reads: The number of Time Out items checked in the OR, and in Medicine
(ICU, GI Clinic, ED, Floor), as recorded on written (live) observation.

12. Table reads: The number of Time Out items checked in Medicine (ICU, GI Clinic, ED,
Floor), recorded with both written (live) observation, and on video observation.

13. 1. How well is Time Out being performed, according to the
predetermined criteria?
2. Do videotaped rehearsals of Time Out, or showing a video of an
“Ideal Time Out,” have an impact on the quality of Time Out
performance? If so, is one method preferable?
3. What are the staff’s attitudes and opinions on Time Out, ideas for
improving safety, and perception of team communication? Do
any of these correlate to Time Out performance?
4. Is there a significant difference in accuracy among the various
methods for evaluating Time Out performance (video
observations, direct observations, or self-report)?

14. From “Another task I have to do"
to “This will help me make my care safer."
It's a sea change.
E. Fishkin, email communication, 8/23/10

15.  Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H., Dellinger, E. P.,
. . .Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global
population. New England Journal of Medicine, 360, 491–499.
 Weiser TG, et al. (2010). Effect of a 19-item surgical safety checklist upon urgent operations in a
global patient population. Annals of Surgery, 251(5), 976-980.

16. Questions about Time Out Project:
Edward Fishkin, MD
Edward.Fishkin@woodhullhc.nychhc.org
MindaAguhob, MEd
Minda.Aguhob@woodhullhc.nychhc.org
SaidaKarimova, MD
Saida.Karimova@nychhc.org
Learn more at Minda’s blog: http://educationhealthcarereform.wordpress.com
Twitter: @Studentsforqual
Institute for Healthcare Improvement (IHI), American College of
Medical Quality (ACMA) and American Medical Student
Association (AMSA) are supporters of the Time Out Project.

17. *Developed by Edward Fishkin, MindaAguhob, SaidaKarimova, and Jonathan Ehinger.
Soon to come on NYC HHC Intranet.
Time Out Training Video for medicine to come, Nov 2012.