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 Stop the Line Policy


 Stop the Line Educational Slide Presentation 

 Printable Version of Policy

I)       APPROVED:        January 19, 2010



            Barnes-Jewish Hospital, St. Louis Children’s Hospital and Washington University School of Medicine (hereinafter collectively referred to as the Academic Medical Center, or “AMC”) are committed to providing patient care of the highest quality.  This policy was developed to support a just culture in which physicians and staff can communicate freely in support of patient safety and to take action, if necessary, with other team members, when patient safety may be at risk.  The AMC organizations encourage individuals to utilize the “stop the line” process when a significant immediate patient safety risk (as defined in Section V) is identified during active provision of care to protect the safety of a patient, and supports them when they do so.




A)   Support a culture of safety by outlining steps to be followed when an individual believes there is a significant Immediate Risk to Patient Safety.

B)   Provide a minimally disruptive method to verify or reinstate the safety of the patient.

C)   Express the expectation of the AMC leadership and Physicians to:

1)   Inform all staff of their responsibility to speak up and “stop the line” when conditions warrant;

2)   Support anyone who speaks up to “stop the line;”

3)   Clarify that failure to respond appropriately to a “stop the line” request may result in disciplinary action.  Examples of inappropriate caregiver responses include but are not limited to:

·         Ignoring requests to “stop the line”;

·         Retaliating in any way to those who ask to “stop the line” in good faith.



When used in this policy, these terms have the following meanings:

  • Stop the Line:  The request of any team member for clarification or interruption of a process when s/he perceives an Immediate Risk to Patient Safety. 
  • When staff or health care providers are engaged or are about to engage in an action believed to be an Immediate Risk to Patient Safety or staff safety; or
  • A staff member or health care provider requests clarity regarding a non-emergency clinical situation that may pose an Immediate Risk to Patient Safety.


·     Immediate Risk to Patient Safety:  Any situation in which a patient’s safety is perceived to be at risk.  Examples may include, but are not limited to:

  • Incompatible blood is sent from the OR while an operation is in progress.
  • During a central line insertion procedure, staff logging the lot number and expiration of the catheter note that the supply had expired.
  • A respiratory therapist notices that a fellow, who had been up all night, was about to insert a chest tube backwards.
  • A proceduralist requests a heparin flush in a heparin allergic patient.
  • During a busy procedural time, the room is not completely cleared before the next patient is brought in.
  • Inconsistent information about the procedure to be performed when H&P, OR schedule, and informed consent are compared.
  • A break in sterile technique during a clean case.
  • A disagreement between members of the care team during a time-out prior to a procedure.
  • Imminent violation of patients’ rights (for instance, failure to obtain informed consent for surgery).
  • Research misconduct with significant risk of imminent patient harm.
  • The wrong side or wrong site is being prepped/draped for an operation or procedure.
  • Caregiver is entering a contact isolation patient room without gown or gloves.
  • A collected pathology specimen is not in the collection cup anymore.
  • An allergy is not identified until just prior to medication administration.



A)   Step One:  When an Immediate Risk to Patient Safety is perceived, communicate in a respectful manner the need to “Stop the Line” and re-evaluate or restore patient safety:

Sample Language

Could we please “Stop the Line” because I have an important question and want to make sure we are delivering safe care to this patient”


B)  Step Two:  If the response to step one is inadequate to restore patient safety, repeat your request to stop the line:

Sample Language

“(Caregiver Name), please stop – we need to review the plan/procedure/situation together before proceeding to make sure we are delivering safe care.”


       C)  Step Three:  If the response to Steps One and Two are inadequate to restore patient safety, immediately invoke the chain of  command by contacting the appropriate immediate supervisor.

  • Once the immediate needs of the patient are resolved, the supervisor shall contact the appropriate AMC Patient Safety Department regarding the incident and the inadequate response to stopping the line.
  • The appropriate AMC Patient Safety Department will notify its leadership, including the CMO, and begin the process of investigation.
  • In the event a WUSM Physician is involved, the appropriate WUSM Department Chief and/or Division Chief will also be notified.
  • Inadequate responses will be investigated promptly and thoroughly by the appropriate AMC’s Patient Safety Department. In the event a WUSM physician is involved, the investigation will be conducted in cooperation with Washington University School of Medicine or the WUSM Faculty Practice Plan as directed by the appropriate Department Chief. In the event that the complaint is against a Department Chief, the Dean of the Washington University School of Medicine will direct the investigation on behalf of WUSM.
  • In the event that remedial measures are necessary, they will be determined based on the severity of the behaviors and according to the AMC organization’s existing policies or Code of Conduct.


The Stop the Line AMC Advisory Group (listed on Exhibit A, which will be revised and updated as necessary) will evaluate the effectiveness of the policy and identify needs for further education and modification to the system. The Advisory Group can then use that knowledge to refine the initiative. 



Stop the Line Advisory Group


Dr. Nikoleta Kolovos, PICU

Dr. Chris Carpenter, ED

Dr. Brian Nussenbaum, Otolaryngology

Dr. Jim Duncan, Radiology

Dr. Andrea Vannucci, Anesthesiology

Dr. Doug Schuerer, Trauma

Dr. Mike Lane, Infectious Diseases

Dr. Robert McKinstry, Radiology

Sally O’Shea, HR

Mary Taylor, Patient Safety


Debbie Hendricks, Oncology

Jody Woodward, Patient Safety

Roz Corcoran, Patient Safety

Sandra Young, HR


 Mara Bollini, Patient Safety

Cathy Myers, HR

April Kutheis, OR

Marla Fernandez, PICU

Betty Langin, PACU

Kathy Hughes, SDS

    Washington University Physicians