Tech in Surgery Prep / Unit 16 TSC 394 review, 2 to 3 minutes
A Time Out That Found the Wrong Side
The idea
A worked example, constructed for this course, shows a time out catching a side discrepancy before incision.
In practice
The patient is scheduled for a right knee arthroscopy. In the preoperative area, the surgeon marks the right knee and the patient confirms the right knee. In the operating room, during positioning, the left leg is prepared by mistake: a new staff member reads the leg holder setup from the previous case. The skin is prepped and draped. The time out begins. The circulating nurse asks everyone to stop. Each person introduces themself. The circulator reads from the consent form: right knee arthroscopy. The scrub person, Pat, looks at the draped knee and sees no site mark; the visible skin shows only prep solution. Pat says that the site mark is not visible on the draped knee. The surgeon lifts the drape edge: the mark is on the other leg. The team stops. The drapes are removed, the patient is repositioned and the correct leg is prepared and draped, with the mark visible. The time out is repeated in full. The procedure proceeds on the right knee. Afterward, the event is reported as a near miss, and the team reviews how leg holders are set between cases.
Where people slip
The error began long before the time out, and every person in the room believed the setup was correct until one person compared what the consent said with what the field showed. The time out worked because Pat looked for the mark and spoke up. A site mark that cannot be seen after draping should always stop the process. Nobody in the room was careless; the system caught an ordinary mistake because one person compared two things that should have matched and said what they saw.
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