Table 2. Errors observed during snapshot audits.
Observed errors in using the SSC | 2015 (N = 54) |
2016 (N = 25) |
---|---|---|
Sign-in | ||
Site was not marked | 1 | |
Equipment was checked but checklist item was not ticked off | 1 | |
Equipment was not tested | 3 | |
SI was performed but not documented | 4 | 4 |
SI-error rate | 5 (9.3%) | 8 (32.0%) |
Team-time-out | ||
TTO was performed but checklist items were not ticked off | 1 | |
TTO was done too early (not all team members were in the OR) | 16 | 6 |
Team members did not focus on TTO | 2 | 1 |
Checklist items of the SI were partially ticked off during TTO | 1 | |
TTO was not stopped despite mentioned operative site mismatch | 1 | |
Checklist items of TTO already ticked off during SI | 1 | |
Team did not check all checklist items | 8 | 1 |
No answer from the team but checklist items were ticked off | 2 | |
SSC coordinator asked and answered the checklist item | 2 | |
TTO-error rate | 32 (59.3%) | 10 (40.0%) |
Sign-out | ||
SO was performed during skin closure | 4 | 1 |
SO was performed after skin closure | 4 | 5 |
Team did not check all checklist items | 4 | |
A team member leaves the OR before the SO | 4 | |
No SO | 1 | 1 |
SO-error rate | 17 (31.5%) | 7 (28.0%) |