Online Program

Patient Safety in Living Donor Liver Transplantation: Sign in and Time Out

Monday, November 2, 2015

Donna Woods, PhD, EdM, Center for Healthcare Studies, Northwestern University, Chicago, IL
Rebeca Khorzad, MEM, CSSBB, Center for Healthcare Studies, Northwestern University, Chicago, IL
Elizabeth Pomfret, MD, Lahey Clinic, Burlington, MA
Mary Ann Simpson, PhD, Lahey Clinic, Burlington, MA
James Guarrera, MD, Columbia University Medical System, New York, NY
Robert Fischer, MD, FACS, Virginia Commonwealth University Medical Center, Richmond, IL
Timothy Curtis, BSN, RN, CEN, Center for Healthcare Studies, Northwestern University, Chicago, IL
Amna Daud, MD, MPH, Center for Healthcare Studies, Northwestern University, Chicago, IL
Ella Reyes, Center for Healthcare Studies, Northwestern University, Chicago, IL
Erin Wymore, MS, Center for Healthcare Studies, Northwestern University, Chicago, IL
Daniela Ladner, MD, MPH, Center for Healthcare Studies, Northwestern University, Chicago, IL

Living donor liver transplantation (LDLT) represents an option for individuals in need of a liver transplant in the context of a deceased donor organ shortage. LDLT involves a healthy donor undergoing a major procedure for no benefit to themselves, to save the life of another.  LDLT is a highly complex procedure with high potential for error and attention to ensuring the safety of this procedure is paramount. The Sign-In and Time-Out are a simple standardized checklist-styled protocol, performed to validate critical surgical and patient information. Sign-in occurs before induction of anesthesia and Time-out occurs before skin incision. The standardized Sign-In and Time-Out checklists improve patient safety by providing a final verification that all elements are correct and understood by all of the members of the operative team before the start of the operative procedure. 


Video Observation were conducted in 8 living donor hepatectomies procedures at three participating Adult to Adult Living Donor Liver Transplantation Cohort Study (A2ALL) centers between 2012-2014. Surgeries were recorded by a professional team of videographers, via 3 cameras at different angles.

Videos were reviewed to identify that sign in and time out occurred and the time stamp. The quality of sign in and time out was also evaluated for performance of each of the elements of the protocol performed (yes/no):

  • Patient's Identity
  • Procedure
  • Site Marked
  • Allergies
  • Antibiotics
  • Patient Position
  • Equipment
  • Blood Type

Evaluation of whether the whole operative Team was focused on the Sign-in and Time-out was also performed (yes/no).


Eight video observations representing 4495 minutes were collected and reviewed by three reviewers.

The videos revealed that Sign-In was performed 83% of the time and the complete Sign-In protocol was performed for 20% of the procedures.  The elements most frequently omitted included Team Introduced (50%) and Procedure (50%) followed by Antibiotics Given (75%).  The full team was focused on the Sign-In 80% of the time.

The Time-out occurred in 100% of the videoed procedures, however adherence to the institutional protocol occurred 38% of the time. The team was focused on the Time-out for 75% of the procedures videoed. The most frequently omitted elements were equipment (62%), patient positioning (50%) and site marked (32%) .


Despite the importance of safety in the context of LDLT, and the demonstrated improvement in surgical safety from the Sign-In and Time-Out, performance of the Sign-In and Time-Out is inconsistent and when performed critical elements are routinely omitted.

Learning Areas:

Administer health education strategies, interventions and programs
Clinical medicine applied in public health
Planning of health education strategies, interventions, and programs

Learning Objectives:
Describe the safety value for conducting standardized Sign-In and Time-Out. Discuss the effectiveness of the implementation of surgical Sign-In and Time-Out. Discuss the challenges for conducting the surgical Sign-In and Time-Out and potential negative impact of not conducting the Sign-In and Time.

Keyword(s): Hospitals, Outcomes Research

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been the PI and Co-I of many federal and foundation funded investigations focused on the considerable public health problems of patient safety and healthcare quality.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.