Scientific Articles   |    
Surgical Site Signing and “Time Out”: Issues of Compliance or Complacence
Geoffrey Johnston, BSc, MBA, MD1; Lee Ekert, MD1; Elliott Pally, BSc, MD1
1 Division of Orthopaedics, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada. E-mail address for G. Johnston: geoff.johnston@saskatoonhealthregion.ca
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Investigation performed at the Saskatoon Health Region and the University of Saskatchewan, Saskatoon, Saskatchewan, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2577-2580. doi: 10.2106/JBJS.H.01615
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Background: Wrong-site surgery remains a common problem as voluntary preoperative skin-marking protocols have met only limited success. The purpose of the present study was to investigate orthopaedic surgeons with regard to their site-signing practices and "time out" procedural compliance for emergent and nonemergent surgical cases in a single health-care region before and after the institution of the "time out" protocol of the Joint Commission on Accreditation of Healthcare Organizations.

Methods: In the first study, performed in 2006, the presence of the initials of either the surgeon or the surgical resident in the draped surgical field was documented at the time of forty-eight procedures over a three-month period. In a second study, performed a year later, 231 randomly selected procedures were similarly evaluated, as was the performance of the newly adopted "time out" process.

Results: In the first study, after surgical field draping, the surgeon's initials were visible in 67% of emergent cases and 90% of elective cases. In the second study, the surgeon's initials were visible in 61% of emergent cases and 83% of elective cases. The "time out" was performed prior to the skin incision in 70% of the cases, was performed after the incision in 19%, and was not performed at all in 11%.

Conclusions: Orthopaedic surgeons should recognize the value of preoperative skin signing for all procedures and the additional value of the "time out" protocol. We recommend that surgeons strive for 100% compliance with both strategies.

Figures in this Article


    time out
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    Geoffrey Johnston, MD
    Posted on November 30, 2009
    Dr. Johnston and colleagues respond to Dr. Pollak
    Division of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

    The authors thank Dr. Pollak for his interest. The purpose of the study was to evaluate the compliance of orthopaedic surgeons to limb signing and “time-out” protocols within a health region in an era before the local introduction of the WHO checklist. The results simply revealed that compliance to these protocols was generally high, but not universal, and that there were practices such as orthopaedic trauma wherein compliance, for one reason or another, was less than in non-emergent practice.

    Wrong site/limb/patient surgery is a highly visible target in the broad realm of patient safety, and is preventable. Although critics might suggest that the rate is deceptively small, the absolute numbers are many. Causes for error involve not only the surgeon but also all hospital personnel who are involved in the processing of the patient from the point of entry in the treatment center to the operating table. Limb signing as per the protocols of the North American national orthopaedic associations will decrease the risk of wrong site/limb/patient surgery – ask any surgeon who has committed such an error. The “time-out”, as a summative process, permits both the surgeon and the surgical team formalized final, or last chance, reflection on the proposed procedure before the surgical incision is to be made, thereby theoretically minimizing the risk of system-derived error.

    If a checklist system, be it in the form of limb signing or a “time- out” process, decreases the risk of wrong site/limb/patient surgery, then surgeons should support such initiatives, even if there are instances, as Dr. Pollak suggests, in which these “site-verification procedures are incompletely effective”. These processes may seem burdensome, or excessively regulatory to some observers, but one must ask oneself why orthopaedic surgeons, normally efficient to a tee, have so widely adopted these strategies – one might speculate that it is because they believe that they actually work.

    Andrew N. Pollak, MD
    Posted on November 09, 2009
    Surgical Site Signing and "Time Out": Issues of Regulatory Burden or Substance?
    University of Maryland School of Medicine, Baltimore, Maryland

    To the Editor:

    I was disappointed with the paper by Johnston et al (1). While the data demonstrates the likely level of compliance with a regulatory requirement, the conclusions seem wildly unrelated. The jump from low compliance to judgment of the value of the regulation is large and unjustified. Recommending perfect compliance in the future may or may not be a good idea, but this study cannot help us answer that question.

    While pilot checklists have been accepted as critical components of safe air travel, and while the use of checklists prior to insertion of central lines decreases sepsis rates, it is a major leap to assume that checklists in the operating room decrease wrong-site surgery incidents. The paper ignores literature that suggests that site-verification procedures are incompletely effective.

    The authors’ analysis assumes that elimination of wrong-site surgery events represents “marked” improvement in overall patient safety. This seems hard to support in the context of an event that occurs at such a small rate. Other complications such as infection and peri-operative mortality occur far more often. The authors’ data support a statement that compliance is less than perfect. It does not support a relationship between compliance levels and overall patient safety.

    The World Health Organization checklist approach has been associated with significant improvements in important and prevalent adverse events. Compliance may be higher in the context of a more relevant checklist.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.


    1. Johnston G, Ekert L, Pally E. Surgical site signing and "time out": issues of compliance or complacence. J Bone Joint Surg Am. 2009;91:2577-80.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    Connecticut - Orthopaedic Foundation
    OR - The Center - Orthopedic and Neurosurgical Care and Research