(Q) Risk manager of a hospital

You are the risk manager of a hospital. A nurse from the operating room reports that, during a surgery, the head surgeon did not conduct a “time out” to confirm the side and site of the surgery. You question the surgeon, and he denies the incident. There is no injury to the patient.
What is the nature of the risk? Who is at risk? What additional information do you require? What actions can be taken to prevent recurrence of the incident

Assuming that you have assessed the situation and determined that a time out violation did occur, your course of action should be to:
1. Immediately document all details related to the incident in a timely manner.
2. Meet with the head surgeon and explain why a “time out” is necessary and how it can help avoid medical errors or patient injury.
3. Provide additional training for operating room staff on how to correctly conduct time outs, as well as any other protocols required for operating room safety and best practices.
4. Develop an internal policy requiring all surgeons to always conduct “time outs” prior to surgery, which must be signed by each surgeon before performing any procedure in the operating room.

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