implementing aorn recommended practices for a safe ... · continuing education implementing aorn...

CONTINUING EDUCATION

Implementing AORNRecommended Practices fora Safe Environment of Care
ANTONIA B. HUGHES, MA, BSN, RN, CNOR 2.2
www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by

reading this article, reviewing the purpose/goal and objectives,

and completing the online Examination and Learner Evalua-

tion at http://www.aorn.org/CE. A score of 70% correct on the

examination is required for credit. Participants receive feed-

back on incorrect answers. Each applicant who successfully

completes this program can immediately print a certificate of

completion.

Event: #13523

Session: #0001

Fee: Members $13.20, Nonmembers $26.40

The CE contact hours for this article expire August 31, 2016.

Purpose/GoalTo enable the learner to take an active role in implementing

recommended practices for a safe environment of care in his or

her perioperative practice setting.

Objectives

1. Explain strategies for safe patient handling.

2. Discuss elements of fire safety.

3. Describe precautions for safe use of electrical equipment.

4. Discuss appropriate use of clinical and alert alarms.

5. Describe precautions to avoid thermal injuries.

6. Explain actions to take for the patient with latex sensitivity.

7. Describe the components of a chemical hazard risk

assessment.

AccreditationAORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s

Commission on Accreditation.

http://dx.doi.org/10.1016/j.aorn.2013.06.007

� AORN, Inc, 2013

ApprovalsThis program meets criteria for CNOR and CRNFA

recertification, as well as other CE requirements.

AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check

with your state board of nursing for acceptance of this activity

for relicensure.

Conflict of Interest DisclosuresMs Hughes has no declared affiliation that could be perceived

as posing a potential conflict of interest in the publication of

this article.

The behavioral objectives for this program were created

by Liz Cowperthwaite, senior managing editor, and Rebecca

Holm, MSN, RN, CNOR, clinical editor, with consultation

from Susan Bakewell, MS, RN-BC, director, Perioperative

Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell

have no declared affiliations that could be perceived as

posing potential conflicts of interest in the publication of

this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as CE for registered nurses.

This recognition does not imply that AORN or the American

Nurses Credentialing Center approves or endorses products

mentioned in the activity.

August 2013 Vol 98 No 2 � AORN Journal j 153

http://www.aornjournal.org

http://www.aorn.org/CE


RECOMMENDED PRACTICES

Implementing AORNRecommended Practices
for a Safe Environmentof Care
154 j AORN Journal �

ANTONIA B. HUGHES, MA, BSN, RN, CNOR 2.2
www.aorn.org/CE
ABSTRACT

Providing a safe environment for every patient undergoing a surgical or other invasive

procedure is imperative. AORN’s “Recommended practices for a safe environment of

care” provides guidance on a wide range of topics related to the safety of perioperative

patients and health care personnel. The recommendations are intended to provide

guidance for establishing best practices and implementing safety measures in all

perioperative practice settings. Perioperative nurses should be aware of risks related to

musculoskeletal injuries, fire, equipment, latex, and chemicals, among others, and

understand strategies for reducing the risks. Evidence-based recommendations can

give practitioners the tools to guide safe practice. AORN J 98 (August 2013) 154-163.

� AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.06.007

Key words: musculoskeletal injury, fire safety, electrical equipment, clinical alarm,

alert alarm, blanket-warming cabinet, solution-warming cabinet, latex, natural

rubber latex, methyl methacrylate bone cement, formalin.

The AORN “Recommended practices for

a safe environment of care”1 addresses

a broad range of safety topics, including

n musculoskeletal injury,

n fire safety,

n electrical equipment,

n clinical and alert alarms,

n blanket- and solution-warming cabinets,

n medical gas cylinders,

n waste anesthesia gases,

August 2013 Vol 98 No 2

n latex,

n chemicals, and

n hazardous waste.

The recommended practices (RP) document was

originally published in 1988 and has been revised

numerous times. It was revised most recently in 2012

to bring AORN’s recommendations up to date with

new evidence, guidelines, and regulatory changes.

This updated RP document is evidence rated.

Each individual reference is evaluated for strength


� AORN, Inc, 2013



RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org

and quality, and each intervention is rated based

on the level of the supporting evidence. Although

the RP documents have previously been well re-

ferenced, the strength and quality of the evidence

were not always apparent to the reader. To begin

the evidence review process, a medical librarian

conducts a systematic literature search to locate

references related to the topic, including relevant

regulations and professional guidelines. The lead

author and a doctorally prepared evidence reviewer

evaluate each reference and assign each one an

appraisal score. Then the collective evidence that

supports each intervention statement is reviewed,

and a rating is assigned to the intervention. The

RP document has been accepted for inclusion in

the Agency for Healthcare Research and Quality

National Guideline Clearinghouse, a searchable

database of clinical practice evidence-based

guidelines and abstracts.

WHAT’S NEW

Educational Resources

n AORNguidance statement: Safe patient handling andmovement in

the perioperative setting. In: Perioperative Standards and Recom-

mended Practices. Denver, CO: AORN, Inc; 2013: 553-572.

n AORNVideo Library: Electrosurgery: Function, Practice & Safety

[DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all.

n AORN Video Library: Fire Prevention in the Perioperative Suite

[DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all.

n AORN Video Library: Latex in the Perioperative Setting: Strate-

gies for the Patient and Staff Safety [DVD]. http://cine-med.com/

index.php?nav¼aorn&cat¼all.

n Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/firesafety/.

n Periop 101Module: Natural Latex Sensitivity/Allergy. AORN, Inc.

http://www.aorn.org/PeriopModules/.

n Safe Patient Handling and Movement Tool Kit. AORN, Inc. http://

www.aorn.org/ToolKits.

n Workplace Safety Tool Kit. AORN, Inc. http://www.aorn.org/

ToolKits.

Web site access verified April 16, 2013.

Based on the literature re-

view and appraisal, the RP

document was updated to

reflect new evidence. Topics

included in the previous it-

eration of the RP document

have been expanded to ad-

dress additional aspects of

safety for patients and health

care personnel. For example,

Recommendation I, related

to occupational injuries for

health care providers, has

been expanded to include

examples of specific risk-

reduction strategies for

injury prevention. Recom-

mendation II, which ad-

dresses fire safety, now

includes the practice re-

commendation to conduct

a fire risk assessment before

every surgical procedure.

Recommendation III on the safe use of electrical

equipment includes the intervention of completing

regular inspections of equipment before use. In

Recommendation IV, the discussion of alert

alarms has been expanded and an intervention

added regarding the need to communicate any

change to the alarm default parameters. Recom-

mendation V recommends precautions to take in

the event of a malfunction in a blanket- or solution-

warming cabinet. The subject of latex safety has

been added to the RP document in Recommenda-

tion VIII. Care of the patient with a latex allergy

or sensitivity was previously addressed in the

“AORN latex guideline.”2 Recommendation IX

includes the requirement of conducting an annual

chemical risk assessment.

Other significant changes to the content of the

document include deleting topics that are addressed

in other RP documents. Topics previously included

in the “Recommended practices for a safe envi-

ronment of care” that are addressed in other RP

AORN Journal j 155

http://cine-med.com/index.php%3fnav%3daorn%26cat%3dall










http://www.aorn.org/firesafety/

http://www.aorn.org/PeriopModules/

http://www.aorn.org/ToolKits





August 2013 Vol 98 No 2 HUGHES

documents include exposure to surgical smoke3,4;

exposure to chemotherapeutic agents5; incorrect

tubing connections5; and requirements for heating,

ventilation, and air conditioning.6 Exposure to

bloodborne pathogens7 and radiation safety8 are

also outside the scope of this RP document.

RATIONALE

Identifying safety issues is the first step in creating

and maintaining a safe perioperative environment.

The RP document not only identifies hazards

present for health care personnel and patients but

suggests risk-reduction strategies that can be put

into place before a problem occurs. Emphasis is

placed on assessing the environment for hazards

and understanding how to correct and report safety

issues. Perioperative nurses can use the RP docu-

ment to help educate team members about the

potential hazards in the environment and how to

mitigate risk. A multidisciplinary team can use this

RP document to guide development of a quality

management plan and to create policies and pro-

cedures for safety in the perioperative area.

DISCUSSION

Because this RP addresses a broad range of safety

topics, the topics discussed in this article are

limited to musculoskeletal injury, fire safety,

electrical equipment, alarms, blanket- and solution-

warming cabinets, latex safety, and chemicals. The

full RP document should be consulted for more

information on these topics and additional topics

that are not included in this article.

Recommendation I

Perioperative team members should take precau-

tions “to mitigate the risk of occupational injuries

that may result in death, days lost from work, work

restrictions, medical treatment beyond first aid, and

loss of consciousness.”1(p218) A significant hazard

for all health care workers is the risk of musculo-

skeletal injury. Working in the perioperative envi-

ronment may include performing tasks that are

forceful or repetitive, that require maintaining

156 j AORN Journal

awkward or static postures, or that involve physical

exertion (eg, carrying heavy equipment).9 In addi-

tion, surgical and invasive procedure rooms have

cords, booms, equipment on wheels, and the po-

tential for wet floors, all of which can present the

risk of slips, trips, and falls.

Perioperative personnel should consider ad-

ministrative, engineering, and behavioral controls

when developing strategies for injury prevention.

Administrative controls include educating per-

sonnel on ergonomic and safe patient handling

techniques, which can decrease overall occupa-

tional injuries.10 Engineering controls include

having appropriate patient handling equipment;

use of transfer devices should be the norm in the

organization. An example of a behavioral control

is eliminating clutter by bundling and covering

cables on the floor to reduce the risk of team

members tripping over exposed wires and tubes.11

The physical environment should be conducive

to safety. Adequate lighting, adequate storage,

and ceiling-mounted electric or hydraulic booms,

when feasible, can decrease the risk of injuries to

personnel.11-13 The perioperative nurse should be

aware of any potential hazards in the environment

and know where and how to report any deficiencies.

Recommendation II

“Potential hazards associated with fire safety in

the practice setting should be identified, and safe

practices for communication, prevention, suppres-

sion, and evacuation should be established and

followed.”1(p220) Each facility should have a writ-

ten fire prevention plan that is developed by a

multidisciplinary team. The plan should include

team members’ responsibilities, an evacuation

plan, and the frequency and content of fire

safety education.

AORN recommends performing a fire risk as-

sessment before each surgical procedure (Figure 1).

The RN circulator initiates the fire risk assessment,

during which the team pinpoints fire risks and

identifies ways to mitigate those risks. The elements

of the risk assessment should be shared with the

Fire Risk Assessment Tool

A fire risk assessment is performed by the surgical team. The surgical team will assess the patient for potential fire risks: open oxygen source, available ignition source, or surgical site above the nipple line.

Total Score:

3 = High risk 2 = Low risk with the potential to convert to high risk 1 = Low risk

RN circulator: Announce the risk assessment score to the other team members.

Team: Follow the Fire Safety Plan according to unit-specific standards.

Circle appropriate option Yes No

Surgical site above the xiphoid process 1 0

Open oxygen source (patient receiving supplemental oxygen via any variety of face mask or nasal cannula)

1 0

Available ignition source (electrosurgical unit, laser or fiber-optic light source)

1 0

Figure 1. A fire risk assessment tool can be usedbefore the start of each surgical procedure to de-termine whether the procedure includes a risk of fire.Printed with permission from Baltimore WashingtonMedical Center, Glen Burnie, MD.


entire surgical team. The communication includes

identifying the use of ignition sources, potential

oxidizers, and fuel sources. These three elements,

which are necessary for a fire to occur, are known

as the fire triangle (Figure 2). Perioperative nurses

have influence over the fuel sources, which include

clothing, drapes, and prep solutions.

Perioperative nurses should help ensure that an

ignition source does not come into contact with

a fuel source.14 Examples include making sure

a holster device is available to keep the electrosur-

gical active electrode (ie, pencil) from contacting

the drapes when it is not in use and ensuring that

prep solution is dry before the surgeon activates

the electrosurgical device. The RN circulator and

scrub person should make sure that sterile saline

or water is available on the back table to douse

flames if needed.

Fire safety includes having clearly marked exits,

hallways with good egress, and readily available

fire extinguishers, as well as performing regularly

scheduled fire drills. Participating in fire drills

allows nurses and other team members to actively

learn and practice what to do during a fire, where

fire extinguishers are located, when to evacuate,

and the best route for evacuation. A representative

from the perioperative department should coor-

dinate a drill with local fire departments after

coordination with the facility’s fire safety officer.

Fire drills should include a review of the exit

path and how to use a fire extinguisher. The fire

safety officer should conduct a post-fire drill review

with the personnel who participated. The review

should include a discussion about how to safely

evacuate the area and protect patients.

Recommendation III

Perioperative team members should take precau-

tions “to mitigate the risk of injury associated with

the use of electrical equipment.”1(p224) If it is not

handled and cared for correctly, electrical equip-

ment presents a potential risk of fire or injury to

patients and health care personnel.15 For example,

a frayed cord or a cord separating from the plug

could convey an electrical shock or start a fire.

Personnel at every facility should have a mech-

anism in place for regularly inspecting new and

existing equipment for damage periodically and

before use. Perioperative nurses may be asked

to participate in the inspection or to gather neces-

sary equipment. Each facility should identify how

equipment is inspected and how personnel are

made aware that the inspection has been completed

(eg, an updated sticker). Personnel should also

assess the facility’s ability to provide the neces-

sary power source to the equipment. For example,

some equipment (eg, robotics, lasers) requires

specific electrical load capabilities.

Although the previous edition of this RP docu-

ment recommended that use of extension cords

be avoided, the new document allows for the

use of electrical extension cords when appro-

priate. The grade of wire and type of plug should

match the equipment and the facility power source.

Mismatched electrical characteristics can cause

AORN Journal j 157


Figure 2. The AORN Fire Triangle illustrates the threeelements necessary for a fire and the members ofthe perioperative team who frequently influence theelements. Reprinted from Perioperative Standardsand Recommended Practices with permission fromAORN, Inc, Denver, CO. Copyright ª 2013. All rightsreserved.


damage to the equipment and overheating of

the cord.15

Recommendation IV

Alarms in the perioperative setting are intended

to alert personnel to changes in a patient’s clinical

status or to equipment malfunctions. Perioperative

team members should take precautions “to mitigate

hazards associated with non-functioning clinical

and alert alarms or with personnel failing to hear or

failing to act on alarms.”1(p225)

Perioperative nurses use clinical alarm systems

as an adjunct to patient care; however, The Joint

Commission has identified clinical alarms as a

source of potential harm for the patient if they

are not checked and used appropriately.16 Clinical

alarms should be set so that all personnel can hear

the audible alarm over competing noise.17,18 If

default parameters are changed on a clinical alarm,

there must be clear verbal and visual communica-

tion among personnel about what changes were

made. Perioperative RNs should help ensure that

158 j AORN Journal

any changes in the alarm parameters or tone are

included in the patient hand-off communication

between health care providers.19

In each organization, clinical engineering or

biomedical department personnel should develop

procedures for regular testing of clinical and alert

alarms,17,18 and perioperative nurses should un-

derstand how the facility reviews and tests alarms.

The testing may be performed at the beginning of

the day or on a set schedule. Perioperative nurses

also should collaborate with clinical engineering

personnel to help maintain an inventory of devices

with clinical alarms and track the testing of devices.

Recommendation V

A warm blanket may help comfort a patient and

mitigate anxiety during the surgical event; how-

ever, perioperative team members should take

precautions “to avoid thermal injuries related to

warming solutions, blankets, and patient linens

in blanket- and solution-warming cabinets.”1(p225)

Thermal injuries are a potential safety hazard in the

perioperative setting because patients are sedated

and may not be able to communicate any discom-

fort from overheated linens or solutions.

Warming cabinets should be labeled to identify

the items that may be placed in the cabinet. An

example is to label the outside of each cabinet

shelf to indicate the permitted contents (eg, blan-

kets on top, fluid on bottom).20 The temperature

of each unit should be set, monitored, maintain-

ed, and documented according to organizational

policy and manufacturers’ specifications. A man-

ual log may be used if the temperature is not

recorded via an electronic recording system. The

temperature reading should be visible to the per-

son retrieving the item from the warmer so he or

she can verify that the item is warmed to a safe

temperature. Any warmed item that is not the

correct temperature when removed from the war-

mer (ie, is too warm or too cold) may indicate that

the equipment is malfunctioning, and this should

be reported to clinical engineering or biomedical

department personnel.21


Fluid-warming cabinets should be labeled

“for fluid only.” Fluid manufacturers have

recommendations for temperature settings and for

the length of time that fluids may be warmed

safely. Perioperative nurses should label any

solutions placed in a warming cabinet with the

date that the solution was placed in and removed

from the cabinet to help determine when the

solution has reached its maximum shelf life and

ensure it has not been in the warming cabinet

for longer than the solution manufacturer’s rec-

ommended warming time.20 “The temperature of

solutions on the sterile field should be remeasured

before administration.”1(p226) Solutions intended

for IV administration should be warmed only with

technology specifically designed to warm these

solutions because these may overheat if placed

in a warming cabinet.20,22

Recommendation VIII

The “AORN latex guideline”2 has been retired, and

the recommendations related to latex safety have

been updated and included in the current edition

of the “Recommended practices for a safe envi-

ronment of care.” The recommendation states,

“A protocol to establish a natural rubber latexesafe

environment should be developed and imple-

mented.”1(p229) An allergic reaction to latex could

cause a patient to experience anaphylaxis during

a surgical procedure.23-25 In addition, health care

personnel are frequently exposed to latex in the

surgical environment and thus are at risk for de-

veloping latex sensitivity.26 Latex exposure may

occur through contact with products containing

latex or through airborne particles. Perioperative

personnel should wear low-protein or powder-free

latex gloves or latex-free gloves to minimize their

own latex exposure.27

AORN’s latex recommendations include con-

ducting a thorough preoperative assessment of each

patient. In the assessment, the perioperative RN

should address at least the patient’s history of long-

term bladder care, history of multiple surgical

procedures, food allergies (eg, banana, kiwi,

avocado, chestnut, raw potato), and occupational

exposure to latex. Patients with latex sensitivity or

allergy should be identified with a bracelet or

wristband, on the medical record, and on the

patient’s bed. The patient should be scheduled

as the first patient of the day, because potentially

fewer latex proteins will be airborne in the OR if

no other procedures have been performed in the

OR that day.28

The perioperative RN can help provide the latex-

sensitive or -allergic patient with a latex-safe

environment by gathering non-latex products,

removing products that contain latex from the

room, and posting signs on the doors of the OR

to alert personnel that the patient has a latex

sensitivity or allergy. The nurse should include

a patient’s latex sensitivity or allergy in hand-off

communication to other health care personnel.24

When withdrawing medication from a vial, the

perioperative nurse should not remove the stopper

of the vial. In a review of the literature, no evidence

was found to support the practice of removing

medication vial stoppers to prevent contact with

latex in the stopper; the medications may already

contain latex from contact with the stopper during

transport and storage.25 The stopper should be

punctured only once to decrease the possibility of

introducing latex proteins into the medication.25

A multidisciplinary team approach should be

taken in caring for patients with latex sensitivity

or allergy. A member of the materials management

team should review current and potential purchases

of products containing latex with the clinical staff.

After the products are identified, clinical per-

sonnel on the value analysis team may be able

to assist with appropriate purchase selections for

latex-safe products.

Recommendation IX

Improper handling of chemicals can result in injury

to health care personnel and patients (eg, burns, eye

damage, respiratory problems). As required by the

Occupational Safety and Health Administration,29

health care personnel must take precautions “to

AORN Journal j 159



mitigate the risks associated with the use of

chemicals in the perioperative setting (eg, methyl

methacrylate, glutaraldehyde, formalin, ethylene

oxide).”1(p231) The RP document provides guidance

on the use of each of these chemicals.

Health care organizations must follow the most

stringent of the federal, state, or local regulations

for chemical handling and disposal. Safety data

sheets, formerly called material safety data sheets,

must be readily accessible to employees within the

practice setting.29

The health care organization must annually per-

form a chemical hazard risk assessment within the

unit or facility that includes requirements for han-

dling, storing, and disposing of chemicals and for

managing spills and treating chemical exposures.29

Each perioperative health care provider has a re-

sponsibility to know how and where to seek infor-

mation regarding chemicals in his or her practice

setting. A hazardous chemical spill drill could be

performed in addition to annual fire safety drills.

The Final Four

The final four recommendations in each AORN RP

document discuss education/competency, docu-

mentation, policies and procedures, and quality

assurance/performance improvement, as appli-

cable. These four topics are integral to the imple-

mentation of AORN practice recommendations.

Personnel should receive initial and ongoing edu-

cation and competency validation as applicable

to their roles. Implementing new and updated rec-

ommended practices affords an excellent opportu-

nity to create or update competency materials and

validation tools. AORN’s perioperative competen-

cies team has developed the AORN Perioperative

Job Descriptions and Competency Evaluation

Tools30 to assist perioperative personnel in devel-

oping competency evaluation tools and position

descriptions.

Documentation of nursing care should include

patient assessment, plan of care, nursing diagnosis,

and identification of desired outcomes and inter-

ventions, as well as an evaluation of the patient’s

160 j AORN Journal

response to care. Implementing new or updated

recommended practices may warrant a review or

revision of the relevant documentation being used

in the facility.

Policies and procedures should be developed,

reviewed periodically, revised as necessary, and

readily available in the practice setting. New or

updated recommended practices may present an

opportunity for collaborative efforts among nurses

and personnel from other departments within the

facility to develop organization-wide policies

and procedures that support the recommended

practices. The AORN Policy and Procedure

Templates, 3rd edition,31 provides a collection of

30 sample policies and customizable templates

based on AORN’s Perioperative Standards and

Recommended Practices.32 Quality assessment

and improvement activities assist in evaluating

the quality of patient care, the presence of environ-

mental safety hazards, and the formulation of plans

for taking corrective actions. For details on the

final four practice recommendations that are specific

to the RP document discussed in this article, please

refer to the full text of the RP document.

AMBULATORY PATIENT SCENARIO

A busy, six-room outpatient surgical facility

located in the Midwest routinely prepares its

patients with a preoperative telephone call. The

preoperative nurse asks the patient about health

history, including a family history of malignant

hyperthermia, and about medication and food

allergies. The patient receives education related

to the surgical procedure and surgeon preferences.

Ms D is a 35-year-old woman scheduled for

a laparoscopic umbilical hernia repair. The patient

is herself a perioperative RN, and during her pre-

operative assessment, she tells the preoperative

nurse that she has sensitivity to latex. The preop-

erative nurse immediately reports the patient’s

latex sensitivity to the perioperative team.

TheRNcirculator and the scrub person prepare the

OR according to the surgeon’s preferences and with

consideration for the patient’s latex sensitivity. They


post signs stating “LatexAllergy” on theORdoors to

alert anyone entering the room. They examine each

item carefully to determine whether it contains any

latex and remove those that do from the OR, sub-

stituting latex-free alternatives. They complete the

counts, and the RN circulator goes to meet Ms D.

The nurse confirms the intended procedure with Ms

D, and they discuss her latex sensitivity. The RN

circulator explains that non-latex gloves will be used

and that all of the products in the room have been

inspected to make sure they do not contain latex.

A nursing diagnosis includes the potential for

hypothermia and retained foreign object and the

need to implement latex allergy precautions. A

forced-air warming device is placed on the patient

before the induction of anesthesia. The counts

are correct throughout the procedure. No signs

and symptoms of latex allergy are noted during

the procedure.

The patient’s surgery is completed without

complication. The RN circulator includes the

information about the patient’s latex sensitivity

in the hand-off report to the postanesthesia care

unit nurse. The patient recovers as expected and

meets all criteria for discharge to home.

Resources for Implementation

n AORN Syntegrity� Framework. AORN, Inc. http://www.aorn.org/

syntegrity.

n ORNurseLinkTM. http://ornurselink.aorn.org.

n Perioperative Job Descriptions and Competency Evaluation Tools

[CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/

JobDescriptions.

n Policy & Procedure Templates [CD-ROM]. 3rd ed. Denver, CO:

AORN, Inc; 2013.

n Ambulatory Surgery Center Resources [CD-ROM]. Denver, CO:

AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/

Ambulatory_Surgery_Center_Resources.aspx

Editor’s notes: AORN Syntegrity is a registered trademark and

ORNurseLink is a trademark of AORN, Inc, Denver, CO.

Web site access verified April 16, 2013.

HOSPITAL PATIENTSCENARIO

The environmental safety

manager, OR manager, chief

of anesthesia, and perioper-

ative educator in an urban,

mid-Atlantic community

hospital plan to conduct an

unannounced fire drill. The

hospital safety officer notifies

the local fire department and

the insurance carrier with the

date and time of the event.

The time is scheduled as

an inservice education pro-

gram for personnel from

the surgical and anesthesia

departments; however, the

participants are unaware that the subject of the

education program will be a fire drill. On the day of

the drill, perioperative personnel are separated into

three rooms, and each room has an assigned leader

who distributes scripts for the drill. The leader

assigns each person a role (ie, RN circulator, scrub

person, surgeon, anesthesia professional, nursing

assistant, student) before the scenario starts.

In room one, the group scenario describes a

patient undergoing a tracheostomy on a patient

care bed when the bed begins to emit smoke from

the motor area. The leader watches how group

members respond to the situation. Several team

members leave the room in search of fire extin-

guishers and to alert the charge nurse. The leader

determines that too much time lapses and de-

clares that everyone in the room died from

smoke inhalation.

In room two, the group scenario describes

a patient undergoing an upper body procedure

when the electrosurgical device begins to shoot

flames across the room. This group quickly pulls

the fire box alarm and gathers up the patient to

evacuate the room. They choose to leave by an old,

unused loading dock exit because the exit is close

AORN Journal j 161

http://www.aorn.org/syntegrity

http://www.aorn.org/syntegrity

http://ornurselink.aorn.org

http://www.aorn.org/JobDescriptions

http://www.aorn.org/JobDescriptions

http://www.aorn.org/Education/Ambulatory/Ambulatory_Surgery_Center_Resources.aspx

http://www.aorn.org/Education/Ambulatory/Ambulatory_Surgery_Center_Resources.aspx



to the main OR doors. The group members discover

that they cannot bring the patient, who is on the OR

bed, down the blocked ramp. The scenario ends at

this point because the team is not successful in

evacuating the patient.

In room three, the group scenario describes a fire

that develops during a surgical procedure because

the electrosurgical active electrode (ie, pencil)

lying on the drape is accidentally activated and

ignites the drapes that are covering the patient.

The group members are able to smother the flames

with normal saline from the back table. They

elect not to evacuate the patient because the fire

has been extinguished. The drapes are removed

from the patient and the patient is assessed for

injury. It is determined that the patient has not been

injured. The patient is re-draped and the sterile field

re-established. The procedure is resumed.

After all three scenarios conclude, the safety

officer conducts a post-drill briefing with all

involved personnel. They evaluate each scenario

and highlight the weak points. In the first scenario,

the patient should have been transferred quickly

from the bed to a stretcher or to another OR bed.

The smoking bed should have been isolated and the

fire extinguished. The second group relates that they

tried to evacuate, but the exit ramp was blocked,

which taught the group that the loading dock exit is

only safe for personnel and patients who can walk.

The third group reacted the fastest to their scenario.

Lessons learned from that scenario were that fire can

erupt very quickly and the response must be fast to

prevent harm.

CONCLUSION

The AORN “Recommended practices for a safe

environment of care”1 encompasses a wide range of

topics, and the importance of a safe environment of

care is clearly outlined. Each topic in the document

can have a significant effect on patient and personnel

safety. Key takeaways include the following:

n Musculoskeletal injuries often can be prevented

with the use of transfer devices and other

measures.

162 j AORN Journal

n Fire safety involves the entire health care team;

vigilance with each patient interaction will lead

to a reduced risk of surgical fires.

n Health care team members should use electrical

devices and components safely and correctly to

avoid potential harm.

n Clinical alarms and alert alarms can notify

personnel of a patient’s changing condition or

an equipment malfunction as long as they can

be heard above competing noise.

n Perioperative team members should know how

to monitor and maintain correct temperatures in

warming devices.

n Screening patients for latex sensitivity or allergy

before surgery and using latex-safe products

increases the safety of the environment.

n Improper handling of chemicals can result in

injury to health care workers and patients.

Safety data sheets must be readily accessible

to health care workers for every potentially

hazardous chemical in the practice setting.

The “Recommended practices for a safe envi-

ronment of care” outlines how perioperative

personnel should practice within the recommen-

dations. Perioperative nurses should review the

RP document with their colleagues and managers

to help develop clear and comprehensive policies

and procedures for their facilities. Health care

workers and patients expect and deserve a safe

environment.

References1. Recommended practices for a safe environment of care.

In: Perioperative Standards and Recommended Prac-

tices. Denver, CO: AORN, Inc; 2013:217-241.

2. AORN latex guideline. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2012:

605-620.

3. Recommended practices for electrosurgery. In: Peri-

operative Standards and Recommended Practices.

Denver, CO: AORN, Inc; 2013:125-141.

4. Recommended practices for laser safety in the peri-

operative practice setting. In: Perioperative Standards

and Recommended Practices. Denver, CO: AORN, Inc;

2013:143-156.

5. Recommended practices for medication safety. In:

Perioperative Standards and Recommended Practices.


http://refhub.elsevier.com/S0001-2092(13)00681-9/sref1

















6. Recommended practices for a safe environment of care:

part II. In: Perioperative Standards and Recommended

Practices. Denver, CO: AORN, Inc. In press.

7. Recommended practices for prevention of transmissible

infections in the perioperative practice setting. In: Peri-

operative Standards and Recommended Practices.


8. Recommended practices for reducing radiological expo-

sure in the perioperative practice setting. In: Perioper-

ative Standards and Recommended Practices. Denver,

CO: AORN, Inc; 2013:295-304.

9. Esser AC, Koshy JG, Randle HW. Ergonomics in office-

based surgery: a survey-guided observational study.

Dermatol Surg. 2007;33(11):1304-1313.

10. Reddy PP, Reddy TP, Riog-Francoli J, et al. The

impact of the Alexander technique on improving

posture and surgical ergonomics during minimally

invasive surgery: pilot study. J Urol. 2011;186(4

suppl):1658-1662.

11. Cappell MS. Accidental occupational injuries to en-

doscopy personnel in a high-volume endoscopy suite

during the last decade: mechanisms, workplace hazards,

and proposed remediation. Dig Dis Sci. 2011;56(2):

479-487.

12. van Det MJ, Meijerink WJ, Hoff C, Tott�e ER, Pierie JP.

Optimal ergonomics for laparoscopic surgery in mini-

mally invasive surgery suites: a review and guidelines.

Surg Endosc. 2009;23(6):1279-1285.

13. AORN guidance statement: Safe patient handling and

movement in the perioperative setting. In: Perioperative

Standards and Recommended Practices. Denver, CO:

AORN, Inc; 2013:553-572.

14. Rinder CS. Fire safety in the operating room. Curr Opin

Anaesthesiol. 2008;21(6):790-795.

15. NFPA 99: Health Care Facilities Code Handbook.

Quincy, MA: National Fire Protection Association;

2012.

16. Medical device alarm safety in hospitals. Sentinel Event

Alert. April 8, 2013;50. http://www.jointcommission

.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF.

Accessed June 13, 2013.

17. Clinical Alarms Task Force. Impact of clinical alarms on

patient safety: a report from the American College of

Clinical Engineering Healthcare Technology Foundation.

J Clin Eng. 2007;32(1):22-33.

18. A Siren Call to Action: Priority Issues from the Medical

Device Alarms Summit. Arlington, VA: Association for

the Advancement of Medical Instrumentation; 2011.

19. Brown JC, Anglin-Regal P. Clinical alarm management:

a team effort. Biomed Instrum Technol. 2008;42(2):

142-144.

20. Warming cabinets. Oper Room Risk Manag. 2010;

2(Surgery 7). https://www.ecri.org/Documents/RM/

ORRM_TOC/SU7ES.pdf. Accessed June 19, 2013.

21. Huang S, Gateley D, Moss AL. Accidental burn injury

during knee arthroscopy. Arthroscopy. 2007;23(12):1363.

e1-1363.e3.

22. Limiting temperature settings on blanket and solution

warming cabinets can prevent patient burns. Health

Devices. 2005;34(5):168-171.

23. Pollart SM, Warniment C, Mori T. Latex allergy. Am

Fam Physician. 2009;80(12):1413-1418.

24. Mertes PM, Lambert M, Gu�eant-Rodriguez RM, et al.

Perioperative anaphylaxis. Immunol Allergy Clin North

Am. 2009;29(3):429-451.

25. Heitz JW, Bader SO. An evidence-based approach to

medication preparation for the surgical patient at risk

for latex allergy: is it time to stop being stopper poppers?

J Clin Anesth. 2010;22(6):477-483.

26. Lieberman P, Nicklas RA, Oppenheimer J, et al. The

diagnosis and management of anaphylaxis practice

parameter: 2010 update. J Allergy Clin Immunol. 2010;

126(3):477-480.

27. Power S, Gallagher J, Meaney S. Quality of life in health

care workers with latex allergy. Occup Med (Lond).

2010;60(1):62-65.

28. Bernardini R, Catania P, Caffarelli C, et al. Perioper-

ative latex allergy. Int J Immunopathol Pharmacol.

2011;24(3 suppl):S55-S60.

29. Occupational Safety and Health Standards. Toxic and

hazardous substances: hazard communication. 29 CFR

x1910.1200. Occupational Safety and Health Adminis-

tration. http://www.osha.gov/pls/oshaweb/owadisp.show

_document?p_table¼STANDARDS&p_id¼10099. Ac-

cessed April 9, 2013.

30. Perioperative Job Descriptions and Competency Evalu-

ation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012.

31. Policy and Procedure Templates [CD-ROM]. 3rd ed.

Denver, CO: AORN, Inc; 2013.

32. Perioperative Standards and Recommended Practices.

Denver, CO: AORN, Inc; 2013.

Antonia B. Hughes, MA, BSN, RN, CNOR, is

a perioperative education specialist, Baltimore

Washington Medical Center, Edgewater, MD.

Ms Hughes has no declared affiliation that could

be perceived as posing a potential conflict of

interest in the publication of this article.

This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon

which it is based and is not intended to be a replacement for that document. Individuals who are developing and

updating organizational policies and procedures should review and reference the full recommended practices

document.

AORN Journal j 163




































http://www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF

http://www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF











https://www.ecri.org/Documents/RM/ORRM_TOC/SU7ES.pdf

https://www.ecri.org/Documents/RM/ORRM_TOC/SU7ES.pdf



























http://www.osha.gov/pls/oshaweb/owadisp.show_document%3fp_table%3dSTANDARDS%26p_id%3d10099











EXAMINATION
CONTINUING EDUCATION PROGRAM
2.2
www.aorn.org/CEImplementing AORN Recommended
Practices for a Safe Environmentof Care

PURPOSE/GOAL

16

To enable the learner to take an active role in implementing recommended prac-

tices for a safe environment of care in his or her perioperative practice setting.

OBJECTIVES



3. Describe precautions for safe use of electrical equipment.



6. Explain actions to take for the patient with latex sensitivity.

7. Describe the components of a chemical hazard risk assessment.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Educating perioperative personnel on ergonomic

and safe patient handling techniques to prevent

injuries is an example of

a. an administrative control.

b. a behavioral control.

c. an engineering control.

d. a work practice control.

2. A fire risk assessment performed before each

surgical procedure includes

1. pinpointing fire risks.

2. identifying ways to mitigate fire risks.

4 j AORN Journal � August 2013 Vol 98 No 2

3. sharing the elements of the risk assessment

with the entire surgical team.

4. identifying the use of ignition sources,

potential oxidizers, and fuel sources.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

3. The element of the fire triangle that perioperative

nurses most commonly have influence over is

a. the fuel source.

b. the ignition source.

c. the oxidizer.

4. The elements of a fire drill should include

1. the location of fire extinguishers.

� AORN, Inc, 2013


http://www.aorn.org/CE

CE EXAMINATION www.aornjournal.org

2. how to use a fire extinguisher.

3. the best route for evacuation.

4. a post-fire drill review.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

5. Electrical extension cords may be used in the

OR when appropriate as long as the grade of wire

and type of plug match the equipment and the

facility power source.

a. true b. false

6. Changes to the default parameters of a clinical

alarm should be communicated

1. during the patient hand off.

2. to The Joint Commission.

3. verbally.

4. visually.

a. 1 and 2 b. 3 and 4

c. 1, 3, and 4 d. 1, 2, 3, and 4

7. Perioperative nurses should label any solutions

placed in a warming cabinet with the date that the

solution was

1. placed in the cabinet.

2. purchased.

3. removed from the cabinet.

4. manufactured.

a. 2 and 4 b. 1 and 3

c. 1, 2, and 3 d. 1, 2, 3, and 4

8. Topics related to latex sensitivity that the peri-

operative RN should address during the preoper-

ative assessment include

1. food allergies.

2. a history of multiple surgical procedures.

3. occupational exposures.

4. risk factors for malignant hyperthermia.

a. 1 and 4 b. 2 and 3

c. 1, 2, and 3 d. 1, 2, 3, and 4

9. Perioperative personnel should remove the stopper

from medication vials before withdrawing medi-

cation to reduce the potential for contaminating

the medication with latex proteins.

a. true b. false

10. The chemical hazard risk assessments should

include requirements for

1. handling chemicals.

2. managing chemical spills.

3. storing chemicals.

4. treating chemical exposures.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

AORN Journal j 165


LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
2.2
www.aorn.org/CEImplementing AORN Recommended
Practices for a Safe Environmentof Care

1

1

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?


Low 1. 2. 3. 4. 5. High


Low 1. 2. 3. 4. 5. High

3. Describe precautions for safe use of electrical

equipment. Low 1. 2. 3. 4. 5. High


Low 1. 2. 3. 4. 5. High


Low 1. 2. 3. 4. 5. High

6. Explain actions to take for the patient with latex

sensitivity. Low 1. 2. 3. 4. 5. High

7. Describe the components of a chemical hazard risk

assessment. Low 1. 2. 3. 4. 5. High

CONTENT

8. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

9. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

10.Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

166 j AORN Journal � August 2013 Vol 98 No 2

11. Will you change your practice as a result of reading

this article? (If yes, answer question #11A. If no,

answer question #11B.)

1A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: ________________________________

1B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: ________________________________

12. Our accrediting body requires that we verify

the time you needed to complete the 2.2 con-

tinuing education contact hour (132-minute)

program: _________________________________

� AORN, Inc, 2013
