We were in the midst of a mock JCAHO survey and with an emphasis on outpatient services, the surveyor wanted to follow a patient from admission to the ED for chest pain, on to the cath lab for a left heart cath. Now, the patient they chose was a hospital employee, well-known to everyone in the lab and a personal friend of the physician. As is our usual routine, the circulating RN and scrub tech met the patient in the Admit/Recovery Unit, where the physician was talking with the patient. We checked his armband, asked if he understood what procedure he was having and asked his birth date. Then we took him to the cath lab (which is only across the hall). The patient was prepped and draped in the presence of the physician.

Our department director and the surveyor were given gowns, hats, etc. and escorted into the lab, where we initiated our time-out. Dr. X made the mistake of loudly saying This is stupid! I™ve known Joe for years. Obviously, he is the right patient and knows that he™s having a cath! Hey Joe, are still the same person you were in the ARU?

We tried to go on with the proper time-out, but the damage was done. Dr. X was perceived by the surveyor as uncooperative and not participating in the time-out.

Our lab became the poster child for improper time-out and learning to do it properly has become a performance improvement project. We now have a script that we follow to be sure that the time-out is worded correctly, and all staff members participate in the presence of the physician in the procedure room.