It's always important to learn from the mistakes of others. When the Joint Commission recently reported 104 incidences involving wrong-patient, wrong-site and wrong-procedure events — with 60 of those events occurring in Pennsylvania — several nurses at Penn Medicine's Pennsylvania Hospital in Philadelphia decided it was time to reemphasize the importance of the pre-op time out. "The perioperative team's compliance rate with performing time outs was 60%, so we created a multidisciplinary team of nurses, surgeons, clinical directors and anesthesia providers to address the issue," says Margaret Vance, MSN, RN, CNOR, a clinical nurse education specialist at the hospital.

The team discussed an education plan based on audits of the hospital's time out process and focused on building a culture of safety that empowers all team members to call for a full stop to surgery if inaccuracies or concerns are identified during time outs.

"Now, our compliance rate is in the 80% to 90% range," says Ms. Vance. "We've haven't had any reported safety events within the past year."