Editor's Note
Wrong-site surgeries are on the rise, and insufficient surgical time outs are a key contributor, according to new data highlighted by AORN on June 10 in honor of this year’s National Time Out Day on June 11. Based on The Joint Commission’s Sentinel Event Data 2023 Annual Review, AORN reports that wrong-site, wrong-procedure, wrong-patient, and wrong-implant surgeries increased by 26% in 2023. Leading causes include lack of or poorly conducted time outs, distraction or task fixation that impairs team awareness, and the absence of a shared understanding among team members.
As noted by AORN, National Time Out Day is observed annually on the second Wednesday in June to highlight the life-saving impact of the surgical time out. Established in 2004, this initiative shows the critical role perioperative nurses play in leading the pause before incision in order to verify patient identity, surgical site, and procedure. The time out, typically lasting about 2 minutes, is considered the final safety barrier before surgery begins and is meant to encourage team communication and prevent avoidable errors.
The surgical time out is more than a routine protocol—it is an essential safety practice that gives all team members in the OR the authority to speak up and confirm critical details. Time outs might need a reboot, however, as they are meaningful only when done with purpose, not autopilot, an OR Today article published on April 1 argues. Revisiting the foundational 1999 “To Err is Human” report, the article challenges the surgical community to acknowledge a hard truth: despite technological advances, the rate of adverse surgical events has barely improved. Citing a recent study showing that 38% of perioperative cases involve adverse events—nearly half of which are linked directly to the surgical procedure—the article notes that passive adherence to safety processes is no longer enough.
The time out practice can devolve into a box-checking exercise when performed without engagement, the article poses, urging perioperative leaders to break this pattern by varying training methods, refreshing communication, and reinforcing the time out as a collaborative act—not a formality. The call to action includes reframing the time out as a three-phase process aligned with perioperative care:
This approach, modeled after the WHO Surgical Safety Checklist, allows for multiple safety checkpoints and makes space for real-time risk identification. To drive lasting improvement, the article outlines a PDSA (Plan-Do-Study-Act) quality framework. Leaders are advised to evaluate their current checklist, embed time-out reviews into team education, and rotate training tactics, including mock time outs with planted errors, role-switching exercises, and interactive patient journey simulations. The goal: restore a culture where everyone speaks up and every voice counts.
Read More >>