Improving patient safety in the endoscopy unit: utilization of remote video auditing to improve time-out compliance

      Background and Aims

      Patient and procedure verification, or the time-out process (TOP), is considered one of the most vital components of patient safety. It has long been a focus of intervention in the surgical community and recently was incorporated into the American Society for Gastrointestinal Endoscopy guidelines for safety in the GI endoscopy unit. The TOP has had limited attention in the endoscopy literature but remains an area for improvement in clinical endoscopy practice. The aim of this study was to identify barriers and improve TOP compliance rates in our endoscopy unit using remote video auditing (RVA).


      This was a single-center, prospective, pilot initiative in an endoscopy unit at a tertiary care academic medical center. Video cameras with offsite monitoring were installed in each procedure room in our endoscopy suite in November 2016. Baseline TOP compliance rates were audited with RVA over a 2-month period. A multidisciplinary quality improvement team reviewed the data, identified barriers to the TOP, and implemented actionable items in January 2017. TOP compliance rates were again monitored via RVA, and data were collected through October 2018. Pre- and postintervention TOP compliance rates were compared.


      Over the baseline period, 692 procedures were audited and TOP compliance documented. Baseline TOP compliance rate was 69.6%. Identifiable barriers to TOP compliance included a lack of designated team member to lead TOP, inconsistent documentation of TOP, irrelevant safety checklist items not applicable to endoscopic procedures, and lack of patient safety culture. Actionable items implemented in response to these barriers included designation of a TOP leader, visual indication of initiation of TOP, creation of a concise endoscopy-specific safety checklist, and formal notification/education of the entire endoscopy team. Postintervention TOP compliance rates were then audited from January 2017 to October 2018 and included 12,008 procedures. The mean TOP compliance rate significantly improved from baseline (95.3% vs 69.6%; 95% confidence interval, 22.4-29.3; P < .0001). Additionally, the improvement was maintained throughout the entire postintervention observation period.


      TOP compliance rates significantly improved in our endoscopy unit through the use of RVA and implementation of 4 actionable items. Future studies should evaluate the reproducibility of this method in other endoscopy units.


      RVA (remote video auditing), TOP (time-out process)
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        • Griffen F.D.
        • Stephens L.S.
        • Alexander J.B.
        • et al.
        The American College of Surgeons' closed claims study: new insights for improving care.
        J Am Coll Surg. 2007; 204: 561-569
        • Poore S.O.
        • Sillah N.M.
        • Mahajan A.Y.
        • et al.
        Patient safety in the operating room. I. Preoperative.
        Plast Reconstr Surg. 2012; 130: 1038-1047
        • Somville F.J.
        • van Sprundel M.
        • Somville J.
        Analysis of surgical errors in malpractice claims in Belgium.
        Acta Chir Belg. 2010; 110: 11-18
        • McCarthy M.
        WHO surgical safety checklist cuts post-surgical deaths by 22%, US study finds.
        BMJ. 2017; 357: j1935
        • Treadwell J.R.
        • Lucas S.
        • Tsou A.Y.
        Surgical checklists: a systematic review of impacts and implementation.
        BMJ Qual Saf. 2014; 23: 299-318
        • Centers for Medicare & Medicaid Services
        State Operations Manual Appendix L: Guidance for Surveyors: Ambulatory Surgical Centers 2013; Rev 89.
        (Available at:) (Accessed May 1, 2019)
        • Calderwood A.H.
        • Chapman F.J.
        • Cohen J.
        • et al.
        • ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force
        Guidelines for safety in the gastrointestinal endoscopy unit.
        Gastrointest Endosc. 2014; 79: 363-372
        • Overdyk F.J.
        • Dowling O.
        • Newman S.
        • et al.
        Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.
        BMJ Qual Saf. 2016; 25: 947-953
        • Pedersen A.
        • Getty Ritter E.
        • Beaton M.
        • et al.
        Remote video auditing in the surgical setting.
        AORN J. 2017; 105: 159-169
        • Matharoo M.K.
        • Haycock A.
        • Sevdalis N.
        • et al.
        Errors in endoscopy, scope to improve? An analysis of non-technical skills and safety checks in endoscopy.
        Gut. 2012; 61: A277
        • Dubois H.
        • Schmidt P.T.
        • Creutzfeldt J.
        • et al.
        Person-centered endoscopy safety checklist: development, implementation, and evaluation.
        World J Gastroenterol. 2017; 23: 8605-8614
        • Matharoo M.
        • Thomas-Gibson S.
        • Haycock A.
        • et al.
        Implementation of an endoscopy safety checklist.
        Frontline Gastroenterol. 2014; 5: 260-265
        • Kherad O.
        • Restellini S.
        • Menard C.
        • et al.
        Implementation of a checklist before colonoscopy: a quality improvement initiative.
        Endoscopy. 2018; 50: 203-210
        • Matharoo M.
        • Sevdalis N.
        • Thillai M.
        • et al.
        The endoscopy safety checklist: a longitudinal study of factors affecting compliance in a tertiary referral centre within the United Kingdom.
        BMJ Qual Improv Rep. 2015; 4
        • Johnston E.R.
        • Habib-Bein N.
        • Dueker J.M.
        • et al.
        Risk of bacterial exposure to the endoscopist's face during endoscopy.
        Gastrointest Endosc. 2019; 89: 818-825
        • Becq A.
        • Snyder G.M.
        • Heroux R.
        • et al.
        Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes.
        Gastrointest Endosc. 2019; 89: 984-989
        • Grein J.D.
        • Murthy R.K.
        new developments in the prevention of gastrointestinal scope-related infections.
        Infect Dis Clin North Am. 2018; 32: 899-913
        • Kenters N.
        • Tartari E.
        • Hopman J.
        • et al.
        Worldwide practices on flexible endoscope reprocessing.
        Antimicrob Resist Infect Control. 2018; 7: 153
        • Phieffer L.
        • Hefner J.L.
        • Rahmanian A.
        • et al.
        Improving operating room efficiency: first case on-time start project.
        J Healthc Qual. 2017; 39: e70-e78
        • Tagge E.P.
        • Thirumoorthi A.S.
        • Lenart J.
        • et al.
        Improving operating room efficiency in academic children's hospital using Lean Six Sigma methodology.
        J Pediatr Surg. 2017; 52: 1040-1044