ORs vary in how they do time-out, and many don’t follow own policy

How ORs conduct time-outs varies widely—and facilities tend not to follow their own policies. These findings are part of a statewide project in Pennsylvania to learn how wrong-site surgery happens and how to prevent it. As part of the project, researchers observed one or more steps of 48 procedures at 6 hospitals and 1 ambulatory surgery facility in the state. They also analyzed more than 400 wrong-site reports made to Pennsylvania's mandatory reporting system. Facilities in that state must report all health care errors, whether or not they resulted in harm to patients.