WILLMAR -- Before any of the surgery teams at Rice Memorial Hospital or the Willmar Surgery Center make the first incision, there's a final stop as they go down the checklist: Correct patient. Correct procedure. Correct body site.
Then, and only then, is the orange "time-out towel" (or, at the surgery center, an orange tent-like cover) removed from the instrument tray so that the surgeon can pick up the scalpel.
The push to make patient care safer has hospitals, surgery centers and clinics focusing in a far more concentrated way on preventing errors that might lead to surgery on the wrong site or the wrong patient.
It's not that they weren't checking before, said Judy Fladeboe, manager of the Willmar Surgery Center.
But the process has become more deliberate and purposeful, she said.
"I think all of us have had close calls," she said. "Human beings are doing all the steps and nothing is perfect. That's why what we do is repetitive. It's just part of being safe."
"It's all about communicating. The patient is more safe when everyone on the team has open communication," said Deb Doyle, director of perioperative services at Rice Memorial Hospital.
Wrong-site surgery and its variations -- surgery on the wrong patient, or the incorrect procedure on the patient -- is thought to be rare.
There's no national reporting system, however, so the true number of wrong-site surgeries occurring in the United States each year is unknown.
Only a handful of states, Minnesota among them, require hospitals and surgery centers to report these errors and analyze what went wrong so that the root causes can be addressed.
Since 2003, when Minnesota began keeping track of "never" events, hospitals and clinics have reported 97 wrong-site surgeries, nine surgeries on the wrong patient, and 44 involving the wrong procedure.
It's something no patient or surgery team wants happening to them, Doyle said. "It might be relatively rare, but it certainly would have a huge impact if it was one of us."
It seems like an impossible mistake: How could a surgeon remove the wrong kidney, as happened in a well-publicized case last year at a Twin Cities hospital?
But it happens, Doyle said, recalling a couple of non-surgical cases at Rice in which a procedure was done on the wrong site.
"Those physicians thought it would never, ever happen to them," she said.
There's a constant push to stay on schedule, which can increase the chance of unsafe shortcuts, she said. Surgery teams are often multi-tasking, and maybe not communicating, in the final few minutes before starting a surgery.
Interruptions and distractions occur and can break the team's focus, Fladeboe said.
The complexity of the system itself makes it singularly challenging to prevent errors.
At both the hospital and the surgery center, the checklist starts long before the patient arrives in the operating suite. Do the surgeon's notes match the procedure on the schedule? Is the medical record in order? Are X-rays available and properly marked? Has the surgical site been properly marked?
"We don't have the patient sign anything until we've reviewed the details so that everyone is on the same sheet of music," Fladeboe said.
Patients sometimes get upset with the constant checking, she said. "It might look like we're not communicating. In reality we're communicating like crazy, but we're also doing that personal verification. ... It's part of what we're supposed to do routinely."
The time-out represents the last chance to double-check everything before proceeding.
"It is a time out. The clock stops," Doyle said.
The orange time-out towel, which Rice Hospital began using in March, is a visual cue that's meant to reinforce this final step. Rice also installed oversized cue cards last year in all its operating rooms and procedure rooms to help keep the checklist front and center for physicians and staff.
Getting the surgery team on board took some convincing, said Jean Larson, unit coordinator for the operating room and central processing and distribution at Rice.
"The biggest hurdle for us to overcome in the OR was the buy-in," she said.
Initially there were worries that the time-out would take too much time. In practice, however, it takes barely a minute and staff acceptance has been high, Larson said. "Now we don't see the pushback."
Another hurdle: getting everyone on the team to actively participate. When the University of Minnesota did an observational study last year for the Minnesota Department of Health, one of the most common problems was surgery teams who were busy checking IVs and doing other tasks instead of concentrating on the time-out.
Rice was one of the hospitals in that study, and staff learned they needed to improve their time-out process, Doyle said.
"It was a change for us," she said. "It's very expected now."
Because some invasive procedures, such as putting in a chest tube or peripheral catheter, take place outside the operating room, Rice Hospital developed a formal process to help ensure these procedures are done safely as well.
"We have a similar checklist. It goes in the chart," said Jessica Vagle, assistant director and clinical lead for adult inpatient services.
Communication also has been formalized to help ensure a staff person is present to help check and verify whenever a non-surgical invasive procedure is done, she said.
Rice's accomplishments at developing and adhering to safe-site protocols recently earned it a "Safe Site" award from the Minnesota Hospital Association.
The state of knowledge on the most effective practices for preventing wrong-site surgery is still evolving. A drop in the number of wrong-site surgeries in Minnesota between 2007 and 2008 suggests, however, that checklists and time-outs may be helping.
Several close calls -- in at least one case, a clerical error that switched right and left sides -- have been caught before the patient reached the OR, Larson said.
"We have caught things," Fladeboe agreed. "That's the whole idea. We caught things in the past too, but we're just more diligent. We do know it works."