1. Crooks, Elizabeth Anne DNP, RN, CNE


A near-miss experience highlights a limitation of time-out protocols.


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Do you hold your breath at a wedding when the minister asks, "Does anyone have a reason why these two people should not be married?" The congregants are then encouraged to speak now or forever hold their peace. There is a valuable lesson in that question for nurses and other health care team members who use time-out protocols.

Figure. Elizabeth An... - Click to enlarge in new window Elizabeth Anne Crooks

I recently underwent a colonoscopy for colorectal screening, as recommended by the U.S. Preventive Services Task Force for adults ages 50 or above. I coped with the discomfort of the procedure's preparation with fluids and lemon popsicles. Even so, by the time I arrived for my appointment the skin on the back of my hands tented when pinched.


The brief admission process included a short history and set of vital signs. I mentioned my dehydration to the nurse. After some difficulty raising a vein, the nurse was able to establish intravenous access. Next, I was placed on a cardiac monitor that revealed a sinus rhythm of 46 to 52 beats per minute, well below my usual resting rate in the mid-70s. I shared my concern about this rate with my nurse. Since I was asymptomatic, she reassured me that she would alert the gastroenterologist to my bradycardia upon transfer to the procedure suite.


In the GI suite, as the alarm on my cardiac monitor repeatedly signaled a low rate, I reiterated my concerns to the physician and nurse. They responded that they would adjust my sedation to accommodate my bradycardia. After helping me into the proper position, they stopped to perform the time-out procedure (right patient, right procedure, right site) required by the Joint Commission Universal Protocol. Satisfied that my safety was ensured, they proceeded with the colonoscopy.


Moments later, as the team was midprocedure, my heart rate and blood pressure fell dangerously. I remember waking in distress and hearing the monitor alarming. The team was working rapidly to stabilize me with fluids and medications. I was lucky that the team's prompt emergency response restored my stability. I would soon learn that I had become one of the 1% of colonoscopy patients to experience acute intraprocedural cardiopulmonary complications. Although I was discharged home later in the day, my recovery took much longer than expected. Knowledge that my outcome could have been catastrophic motivates me to reflect on processes that may have placed me at risk.


As a nurse educator, I teach students the CUS technique developed by the Agency for Healthcare Research and Quality for expressing patient safety concerns-this simple approach empowers anyone on the team to express concern, state they are uncomfortable, and assert that there is a safety issue. The point is to "stop the line" and reevaluate your team's approach. The success of this strategy, however, depends on a team member becoming uncomfortable. In my case, the team's confidence in the preprocedure checklist may have resulted in a false sense of security and dismissal of important clinical signs. While checklists are important, overreliance on them may lead to the omission of other practices, such as astute clinical observation, that support patient safety.


Checklists cannot think for us. They can, however, guide our thought processes. Current recommendations for time-out protocols do not include a prompt that directs the team to consider clinical findings that may signal a safety issue. Instead, the focus is on the correct patient receiving the correct procedure. Incorporating two simple questions into our quality and safety processes-"Can anyone think of a reason why we should not proceed?" and "Is anything unexpected or unusual happening with this patient?"-may provide the team with the cue they need to reconsider clinical red flags prior to invasive procedures. In doing so, team members, like wedding guests, would be given one more opportunity to "speak now."