Viewpoint: A Limitation of Preprocedure Checklists

I once worked at a hospital where some of the surgeons regarded safety checklists as an inconvenience. They saw them as bothersome intrusions by the nursing staff into the surgical suite. One OR nurse was even “counselled” by her supervisor (in the presence of the complaining surgeon) to avoid upsetting the doctors by using the preprocedure time-out.

How important are these tools? Are we using them well, or do we speed through them as rote exercises? Might we even expect too much of them? In AJN’s July Viewpoint, nurse Elizabeth Anne Crooks relates a frightening episode (she was the patient) that led her to think about time-outs in a different way.

Crooks was about to undergo a colonoscopy. The clinical team seemed relatively unconcerned about her bradycardia, which was a significant change from her normal heart rate. After completing the usual time-out protocol, sedation was initiated and the physician began the procedure. Suddenly, Crooks’ heart rate and blood pressure dropped precipitously.

I remember waking in distress and hearing the monitor alarming. The team was working rapidly to stabilize me with fluids and medications.

A routine procedure had suddenly become an emergency.

In reflecting upon her experience, Crooks wonders whether the preprocedure time-out may have given her clinical team a false sense of security—one that led them to downplay a clinically significant change. And yet, as we know, these time-outs focus on ensuring that the correct patient is receiving the correct procedure, and not on other safety issues. Did the ritual use of this tool cause the team to look away from their own clinical observations?

To help ensure that the bigger picture isn’t masked by a checklist, Crooks suggests the addition of two simple questions to preprocedure time-outs:

  • “Can anyone think of a reason why we should not proceed?”
  • “Is anything unexpected or unusual happening with this patient?”

Read more in Forever Hold Your Peace: When Preprocedure Safety Concerns are Missed in the July issue of AJN.


Clinical editor, American Journal of Nursing (AJN), and epidemiologist


  1. Nicole June 29, 2017 at 4:39 am

    Time out is a very important factor to consider

  2. JButler June 28, 2017 at 11:35 am

    Excellent point. A timeout should be a moment for assessing in applying critical judgment. Sometimes we get caught up and checking off the boxes. The two additional questions or significant.

  3. Sharon smith June 28, 2017 at 9:57 am

    There is no substitute for critical thinking. The problem comes in when we add so many documented steps to procedures that there isn’t enough time for thinking. Time outs are important, and should be done thoughtfully for all the right reasons

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