Stop the Line

What does it mean to Stop-the-Line?

• Stop-the-Line is the request of any team member (including patients and families) for clarification/interruption of a process and action when there is an immediate risk to patient or staff safety.
• Stop-the-Line is ceasing any activity or removing equipment that could cause further harm.  

What is an immediate Risk to Patient or Staff Safety?  

Any situation in which safety is perceived to be at risk. Examples may include, but are not limited to:

• Missed Hand Hygiene at moment of patient care.
• Improper use of Personal Protective Equipment (PPE).
• Improper use of Transfer-Lift-Reposition (TLR) procedures and equipment
• When patient/family identifies something is wrong – i.e. wrong medication, wrong procedure.
• Differing views regarding the ability to meet care needs in a safe environment for a patient (e.g. receiving transfers we are unable to accept).
• Omission of care.
• Patient assessment reveals risks such as suicide or VTE, but no actions taken
• Incomplete process for checklists, procedures or best practice e.g. Surgical Checklist, Medication Administration, patient Identifiers, Labeling, Physician Orders, Consent.
• A disagreement between members of the care team or between members of the care team and patients/families regarding the provision of care.
• Differing views regarding the ability to provide safe patient care and the need for alternate care (e.g. different facility).
• Equipment malfunctions, unavailability or failure of equipment that could have or did jeopardize the patient/resident/client and/or staff.  

Each facility or area of care/service will identify its own Stop-the-Line examples for education of staff and patients to the unit, facility or service.

Please see the resources attached as files at the bottom of this page.