From a good surgeon to a great man: National Timeout Day

Today is National Timeout Day; this story marks that.

The surgeon had just finished operating on a 65-year-old woman's hand at a satellite location of a Harvard teaching hospital. Her finger had been locked in a bent position ("trigger finger"), but the wrong operation had been performed: she had had surgery to correct carpal tunnel syndrome. The surgeon realized the error as he began dictating his post-surgical note.

Here's how the mix-up happened: A nurse had marked the correct arm to be operated on, but not the incision site. Several surgeons were behind schedule, stressing the staff. Staff moved the patient to a different operating room, so the nurse who prepared the patient for surgery was not present for the procedure. A tourniquet wasn't in the O.R., so a nurse had to get one, which disrupted the documentation of the procedure. The nursing team changed in the middle of the procedure.

As a result of the error, among other changes, time-outs are now performed more carefully during surgeries to verify that safety protocols are being followed.

The surgeon acknowledged his error, and apologized for it. He has since spoken openly to raise awareness among his peers, even writing an article in the New England Journal of Medicine to teach others. As his boss says, the surgeon "has gone from being known as a good surgeon to being known as a great man."

Advice to patient advocates: Verify that a time-out has been performed before surgery begins.

Read stories about choosing surgery, surgeons, and hospitals in my new book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

Thanks to Helen Haskell for distributing the source story by Marshall Allen in the June 15 issue of the Las Vegas Sun.