I

Priority Patient Safety IssuesIdentified by Perioperative NursesVICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN; PAULA R. GRALING, DNP, RN, CNOR;

YELENA PERKHOUNKOVA, PhD

ABSTRACT

Much of the work done by perioperative nurses focuses on patient safety. Peri-

operative nurses are aware that unreported near misses occur every day, and they use

that knowledge to prioritize activities to protect the patient. The purpose of this

study was to identify the highest priority patient safety issues reported by peri-

operative RNs. We sent a link to an anonymous electronic survey to all AORN

members who had e-mail addresses in AORN’s member database. The survey asked

respondents to identify top perioperative patient safety issues. We received 3,137

usable responses and identified the 10 highest priority safety issues, including wrong

site/procedure/patient surgery, retained surgical items, medication errors, failures in

instrument reprocessing, pressure injuries, specimen management errors, surgical

fires, perioperative hypothermia, burns from energy devices, and difficult intubation/

airway emergencies. Differences were found among practice settings. The infor-

mation from this study can be used to inform the development of educational

programs and the allocation of resources to enhance safe perioperative patient care.

AORN J 97 (April 2013) 402-418. � AORN, Inc, 2013. http://dx.doi.org/10.1016/j

.aorn.2012.06.016

Key words: medical errors, perioperative patient safety, wrong site surgery,

retained surgical items, medication errors, instrument reprocessing, pressure ulcers,

specimen management, surgical fires, hypothermia, burns, airway emergencies.

n recent years, there have been numerous

national initiatives to improve the safety and

quality of patient care in the United States.1-4

In spite of this, recent research has found that 30%

of hospitalized adult patients experience an adverse

event,5 and some near misses go unreported. Many

of these adverse events and near misses occur

during perioperative care of the surgical patient.

The invasiveness of the surgical procedure, the

anesthesia, and the technology used, coupled with

the complexities of teamwork and communication,

402 j AORN Journal � April 2013 Vol 97 No 4

make the perioperative period a high-risk time

for the surgical patient. Nursing care during this

window of time is provided by perioperative RNs

whose priority is patient safety. These individuals

are in a unique position to understand the un-

reported near misses that occur every day and use

that knowledge to prioritize interventions and

activities to protect the patient. Little is known,

however, about what patient safety issues peri-

operative nurses consider a priority to address. This

information is needed to inform the development of

http://dx.doi.org/10.1016/j.aorn.2012.06.016

� AORN, Inc, 2013

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

educational programs and, more importantly, the

allocation of resources to make perioperative

patient care safer.

OBJECTIVES

The purpose of this study was to identify the

highest priority patient safety issues reported

by perioperative RNs. The research questions

addressed were

n What are the highest priority patient safety

issues identified by perioperative RNs?

n How do priorities for patient safety identified by

perioperative RNs vary across types of employ-

ment settings and regions of the country?

n How do priorities for patient safety identified

by perioperative RNs vary by the job role, years

of experience, and educational preparation of

the nurse?

METHODS

We used a descriptive study design, collecting

data through an anonymous electronic survey. We

developed an initial list of potential safety issues by

asking for input from experienced perioperative

nurses. The focus was patient safety, not including

infection control. A category of “other, please

describe” was included to allow for other options.

Next, the survey tool was evaluated for content

validity by perioperative nurses with more than

10 years of experience, including those working

in all five regions of the country. We solicited

experts working in a variety of settings (ie, academic

medical centers, community and federal hospitals,

ambulatory surgery centers [ASCs]) and in a

variety of perioperative nursing roles.

The survey tool screened out respondents who

reported being retired or employed by industry.

We solicited data about the location (ie, state) and

type of facility in which the nurse was employed

and the nurse himself or herself (eg, years of

experience, educational preparation, role) and

instructed the respondent to select the five highest

priority patient safety issues from a list of 24 issues.

We collaborated with AORN for use of the

association’s membership database. AORN sent an

e-mail to all 37,022 members who had an active

e-mail address in the database. The e-mail de-

scribed the survey; included consent information;

invited members to respond; and included a hyper-

link to the survey, which was located within the

REDCap database at the University of Iowa Insti-

tute for Clinical and Translational Science, Iowa

City. Inclusion criteria were ability to read and

write in English and having an e-mail address in

the AORN database. Exclusion criteria included

retired nurses, nurses working for industry, and

nurses who were not currently employed.

The survey was anonymous, and no unique

identifying data were collected. We received

approval for conducting the survey through the

university’s institutional review board. A follow-

up e-mail was sent to remind potential respondents

about the invitation to participate. On completion

of data collection, two independent reviewers

evaluated responses of “other, please describe.”

If both reviewers considered the response to

match one of the options provided, the data

were recoded.

STATISTICAL ANALYSIS

Data were analyzed using SAS Version 9.3.6

Descriptive statistics were used to summarize

employment settings, regions of the country, and

characteristics of the nurse (ie, job role, years of

experience, educational preparation). For each

identified safety issue, differences among groups

defined by employment setting, region, and char-

acteristics of the nurse were examined using the

Pearson chi-square test of independence.

RESULTS

We received 3,137 usable completed surveys.

The number of persons meeting exclusion criteria

is unknown; therefore, we were unable to calculate

a response rate. The majority (81%) of respondents

worked in hospitals, and 18% worked in ASCs

(Figure 1). Of those working in hospitals, more

AORN Journal j 403

Figure 1. Settings in which respondents reported working (N [ 3,137).

Figure 2. Types of hospitals in which respondents reported working (N [ 2,515).

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

than half (53%) worked in community hospitals

and 27% worked in academic medical centers

(Figure 2); 43% worked in medium-sized (ie, 200-

bed to 499-bed) hospitals (Figure 3). Respondents

404 j AORN Journal

reported working in all five regions of the United

States, including the Midwest (26%), Northeast

(24%), Southeast (21%), West (18%), and South-

west (11%).

Figure 3. Hospital size in which respondents reported working (N [ 2,516).

Figure 4. Primary job role reported by respondents (N [ 3,084).

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

Respondents reported working in a variety of

perioperative nursing roles. Half worked in direct

patient care roles (eg, staff nurse/clinician, RN first

assistant [RNFA]), 14% were managers or assistant

managers, 14% were directors, and 11% were

educators (Figure 4). This distribution was similar

AORN Journal j 405

Figure 5. Years of experience in perioperative nursing reported by respondents (N [ 3,053).

Figure 6. Highest educational preparation reported by respondents (N [ 3,089).

406 j AORN Journal

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

TABLE 1. Frequency of Safety IssuesIdentified as High Priority (All Respondents,N [ 3,137)

Safety issue n %

Preventing wrong site/procedure/patient surgery

2,151 68.6

Preventing retained surgical items 1,918 61.1Preventing medication errors 1,351 43.1Preventing failures in instrumentreprocessing

1,290 41.1

Preventing pressure injuries 1,247 39.8Preventing specimen management errors 1,099 35.0Preventing surgical fires 1,094 34.9Preventing perioperative hypothermia 966 30.8Preventing burns from energy devices 821 26.2Responding to difficult intubation/airwayemergencies

728 23.2

Preventing venous thromboembolism 582 18.6Disaster/emergency preparedness 472 15.0Preventing falls 345 11.0Preventing implant/prosthesis mismatch 335 10.7

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

to the AORN membership, with the categories

of staff nurse, manager, and RNFA the same.7

As might be expected, a slightly higher percentage

of directors and educators responded compared

with the percentages in the membership database.

The majority (71%) reported having more than

15 years of perioperative experience (Figure 5).

One-third (38%) reported a bachelor of science

in nursing degree as their highest educational

preparation, 18% reported an associate degree in

nursing as their highest educational preparation,

and 25% reported having an advanced degree (ie,

master’s degree or higher) (Figure 6). This distri-

bution was identical to the AORN membership

for diploma, associate degree, and baccalaureate

preparation. As might be expected, the percent-

age of master’s degree-prepared respondents was

somewhat higher than the percentage in the mem-

bership database.7

Awareness during anesthesia 274 8.7Management of blood glucose levels 179 5.7Preventing blood transfusion errors 178 5.7Other 162 5.2Management of alarms 54 1.7Preventing compartment syndrome 52 1.7Preventing complications from negativepressure

45 1.4

Preventing wrong tubing or tubingmisconnections

30 1.0

Preventing injuries from pressurized 23 0.7

Highest Priority Safety Issues

Overall, the twomost highly rated safety issues were

preventing wrong site/procedure/patient surgery

(69%) and preventing retained surgical items (61%)

(Table 1). More than one-third of the respondents

identified preventing medication errors, failures

in instrument reprocessing, pressure injuries, and

surgical fires as top priorities for action.

hemostatic agents

Preventing medical gas misconnections 14 0.4

Differences Based on Hospital Versus ASCSetting

Nurses working in hospitals identified the fol-

lowing five safety issues as their highest priority:

1. preventing wrong site/procedure/patient

surgery

2. preventing retained surgical items

3. preventing pressure injuries

4. preventing failures in instrument reprocessing

5. preventing medication errors

Nurses working in ASCs identified the following

five safety issues as their highest priority:

1. preventing wrong site/procedure/patient

surgery

2. preventing medication errors

3. preventing failures in instrument reprocessing

4. preventing of retained surgical items

5. preventing surgical fires

Although nurses working in both hospitals and

ASCs most often identified preventing wrong site/

procedure/patient surgery as a high priority safety

issue, there were significant differences between the

two groups (Table 2). Noticeable differences in-

cluded that nurses working in hospitals were more

concerned with preventing retained surgical items

(68% versus 35%, P < .001) and pressure injuries

AORN Journal j 407

TABLE 2. Top Rated Safety Issues by Type of Setting

Safety issue

HospitalsN ¼ 2,529

Ambulatory surgerycenters N ¼ 551

Pn % n %

Preventing wrong site/procedure/patient surgery 1,728 68.3 409 74.2 .006Preventing retained surgical items 1,711 67.7 195 35.4 < .001Preventing medication errors 976 38.6 360 65.3 < .001Preventing failures in instrument reprocessing 1,020 40.3 264 47.9 .001Preventing pressure injuries 1,143 45.2 94 17.1 < .001Preventing specimen management errors 921 36.4 170 30.9 .013Preventing surgical fires 899 35.5 188 34.1 .525Preventing perioperative hypothermia 806 31.9 151 27.4 .040Preventing burns from energy devices 640 25.3 176 31.9 .001Responding to difficult intubation/airway emergencies 560 22.1 163 29.6 < .001Preventing venous thromboembolism 480 19.0 93 16.9 .251Disaster/emergency preparedness 359 14.2 111 20.1 < .001Preventing falls 217 8.6 124 22.5 < .001

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

(45% versus 17%, P < .001) than nurses working in

ASCs, whereas nurses working in ASCs were more

concerned with preventing wrong site/procedure/

patient surgery (74% versus 68%, P ¼ .006) and

medication errors (65% versus 39%, P < .001) than

nurses working in hospitals. Of the 10 most highly

rated issues, nurses working in hospitals were more

likely to identify preventing retained surgical items

and pressure injuries than nurses working in ASCs.

Nurses working in ASCs were more likely to iden-

tify preventing wrong site/procedure/patient sur-

gery, medication errors, failures in instrument

reprocessing, burns from energy devices, and air-

way emergencies than nurses working in hospitals.

Differences Based on Hospital Type andSize and Region

Nurses in all types of hospitals generally agreed

that preventing wrong site/procedure/patient sur-

gery and preventing retained surgical instruments

were the top two priority issues (percentages

ranged from 60% to 73% across hospital types).

However, nurses in federal hospitals were more

concerned with instrument reprocessing failures

than nurses in other types of hospitals (59% versus

36% to 45%, P ¼ .001). Nurses in academic

408 j AORN Journal

hospitals were more concerned with pressure

injuries than nurses in other hospitals (54%

versus 39% to 42%, P < .001). Nurses in rural

hospitals were more concerned with venous

thromboembolism than nurses in other hospitals

(30% versus 16% to 20%, P ¼ .002) (Table 3).

Regardless of hospital size, nurses were very

concerned with preventing wrong site/procedure/

patient surgery (percentages ranged from 67% to

69%). The larger the hospital, the more likely

nurses were to identify prevention of retained

surgical items (percentage increasing from 57% to

74%, P < .001) and pressure injuries (percentage

increasing from 38% to 53%, P < .001) to be

priority safety issues. Nurses in smaller hospitals

(ie, < 200 beds) were more concerned with re-

processing failures (44% to 46% versus 36%

to 38%, P ¼ .001) and management of difficult

airways (25% to 27% versus 16% to 21%, P <

.001) than nurses in larger hospitals (ie, � 200

beds). Nurses in hospitals with fewer than 100 beds

identified prevention of specimen errors as an issue

less often (Table 4).

There was also some variability in priority issues

identified by nurses working in different regions

of the country (Table 5). Nurses working in the

TABLE 4. Top Rated Safety Issues by Size of Hospital

Safety issue

< 100 bedsN ¼ 420

100-199 bedsN ¼ 528

200-499 bedsN ¼ 1,081

> 500 bedsN ¼ 487

Pn % n % n % n %

Preventing wrong site/procedure/ patientsurgery

290 69.0 365 69.1 727 67.3 338 69.4 .778

Preventing retained surgical items 239 56.9 354 67.0 755 69.8 358 73.5 < .001Preventing medication errors 184 43.8 196 37.1 413 38.2 178 36.6 .101Preventing failures in instrument reprocessing 185 44.0 244 46.2 410 37.9 177 36.3 .001Preventing pressure injuries 161 38.3 215 40.7 505 46.7 258 53.0 < .001Preventing specimen management errors 120 28.6 184 34.8 425 39.3 191 39.2 .001Preventing surgical fires 171 40.7 196 37.1 376 34.8 155 31.8 .034Preventing perioperative hypothermia 156 37.1 167 31.6 336 31.1 144 29.6 .076Preventing burns from energy devices 104 24.8 140 26.5 272 25.2 121 24.8 .910Responding to difficult intubation/airway

emergencies105 25.0 142 26.9 230 21.3 78 16.0 < .001

Preventing venous thromboembolism 115 27.4 106 20.1 175 16.2 84 17.2 < .001

TABLE 3. Top Rated Safety Issues by Type of Hospital

Safety issue

CommunityN ¼ 1,329

AcademicN ¼ 683

PublicN ¼ 249

RuralN ¼ 162

FederalN ¼ 92

Pn % n % n % n % n %

Preventing wrong site/procedure/patientsurgery

920 69.2 465 68.1 161 64.7 113 69.8 61 66.3 .665

Preventing retained surgical items 886 66.7 483 70.7 171 68.7 97 59.9 67 72.8 .055Preventing medication errors 545 41.0 242 35.4 95 38.2 63 38.9 29 31.5 .088Preventing failures in instrument reprocessing 541 40.7 247 36.2 100 40.2 73 45.1 54 58.7 .001Preventing pressure injuries 561 42.2 371 54.3 105 42.2 64 39.5 36 39.1 < .001Preventing specimen management errors 497 37.4 267 39.1 79 31.7 53 32.7 25 27.2 .054Preventing surgical fires 505 38.0 215 31.5 80 32.1 60 37.0 36 39.1 .035Preventing perioperative hypothermia 432 32.5 210 30.7 71 28.5 64 39.5 27 29.3 .163Preventing burns from energy devices 342 25.7 184 26.9 54 21.7 30 18.5 28 30.4 .091Responding to difficult intubation/airway

emergencies295 22.2 134 19.6 69 27.7 42 25.9 16 17.4 .048

Preventing venous thromboembolism 260 19.6 109 16.0 43 17.3 48 29.6 16 17.4 .002

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

Northeast and Midwest were more concerned with

pressure injuries than nurses in other regions (44%

versus 35% to 39%, P ¼ .002). Nurses working in

the West and Southwest were more concerned with

responding to difficult intubations/airway emer-

gencies than nurses in other regions (27% to 29%

versus 20% to 24%, P ¼ .002)

Differences Based on Characteristics of theNurse

Priorities identified varied by primary job role of

the nurse. Nurses working in direct patient care

roles (ie, staff nurse/clinician, RNFA) were more

likely than other nurses to identify preventing

pressure injuries, perioperative hypothermia,

AORN Journal j 409

TABLE 6. Top Rated Safety Issues by Job Role (N [ 3,096)

Safety issue

Staff nurses N ¼ 1,562 Others N ¼ 1,534

Pn % n %

Preventing wrong site/procedure/patient surgery 1,026 65.7 1,125 73.3 < .001Preventing retained surgical items 976 62.5 939 61.2 .467Preventing medication errors 654 41.9 695 45.3 .054Preventing failures in instrument reprocessing 586 37.5 701 45.7 < .001Preventing pressure injuries 682 43.7 563 36.7 < .001Preventing specimen management errors 482 30.9 615 40.1 < .001Preventing surgical fires 483 30.9 610 39.8 < .001Preventing perioperative hypothermia 558 35.7 407 26.5 < .001Preventing burns from energy devices 441 28.2 380 24.8 .029Responding to difficult intubation/airway emergencies 429 27.5 297 19.4 < .001Preventing venous thromboembolism 327 20.9 253 16.5 .002

TABLE 5. Top Rated Safety Issues by Region of the Country

Safety issue

NortheastN ¼ 732

SoutheastN ¼ 635

MidwestN ¼ 765

SouthwestN ¼ 329

WestN ¼ 533

Pn % n % n % n % n %

Preventing wrong site/procedure/patientsurgery

521 71.2 467 73.5 515 67.3 222 67.5 352 66.0 .025

Preventing retained surgical items 455 62.2 387 60.9 452 59.1 216 65.7 338 63.4 .261Preventing medication errors 292 39.9 289 45.5 328 42.9 145 44.1 256 48.0 .051Preventing failures in instrument reprocessing 294 40.2 292 46.0 308 40.3 131 39.8 219 41.1 .153Preventing pressure injuries 320 43.7 225 35.4 337 44.1 119 36.2 206 38.6 .002Preventing specimen management errors 294 40.2 218 34.3 265 34.6 97 29.5 187 35.1 .012Preventing surgical fires 256 35.0 236 37.2 295 38.6 115 35.0 170 31.9 .141Preventing perioperative hypothermia 227 31.0 198 31.2 247 32.3 114 34.7 153 28.7 .440Preventing burns from energy devices 205 28.0 179 28.2 199 26.0 90 27.4 117 22.0 .105Responding to difficult intubation/airway

emergencies156 21.3 126 19.8 185 24.2 88 26.7 154 28.9 .002

Preventing venous thromboembolism 129 17.6 114 18.0 156 20.4 65 19.8 100 18.8 .658

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

difficult intubation/airway emergencies, and venous

thromboembolism. Those who reported their pri-

mary job role as more indirect care (ie, charge

nurse, assistant manager, manager, director, edu-

cator, advanced practice registered nurse, quality/

outcomes manager) were more likely to identify

preventing wrong site/procedure/patient surgery,

failures in instrument reprocessing, specimen

management errors, and surgical fires (Table 6).

410 j AORN Journal

The priorities of nurses with work experience of

fewer than 10 years and at least 10 years were

similar with two exceptions: more experienced

nurses were more concerned with surgical fires

(36% versus 31%, P ¼ .015), whereas less

experienced nurses were more concerned with

difficult intubation/airway emergencies (28%

versus 23%, P ¼ .009) (Table 7). Priorities

varied somewhat by educational preparation of

TABLE 8. Top Rated Safety Issues by Highest Education

Safety issue

DiplomaN ¼ 384

AssociatedegreeN ¼ 559

Bachelor’sdegree

N ¼ 1,387

Master’sdegree or

higher N ¼ 759

Pn % n % n % n %

Preventing wrong site/procedure/patientsurgery

267 69.5 405 72.5 949 68.4 526 69.3 .381

Preventing retained surgical items 215 56.0 340 60.8 862 62.1 498 65.6 .015Preventing medication errors 175 45.6 257 46.0 591 42.6 326 43.0 .464Preventing failures in instrument reprocessing 157 40.9 230 41.1 589 42.5 311 41.0 .880Preventing pressure injuries 129 33.6 212 37.9 575 41.5 327 43.1 .008Preventing specimen management errors 132 34.4 169 30.2 465 33.5 330 43.5 < .001Preventing surgical fires 151 39.3 191 34.2 479 34.5 271 35.7 .329Preventing perioperative hypothermia 144 37.5 180 32.2 427 30.8 212 27.9 .010Preventing burns from energy devices 114 29.7 150 26.8 381 27.5 176 23.2 .073Responding to difficult intubation/airway

emergencies87 22.7 158 28.3 327 23.6 154 20.3 .009

Preventing venous thromboembolism 86 22.4 114 20.4 269 19.4 113 14.9 .007

TABLE 7. Top Rated Safety Issues by Working Experience

Safety issue

Work years > 10N ¼ 553

Work years � 10N ¼ 2,500

Pn % n %

Preventing wrong site/procedure/patient surgery 379 68.5 1,743 69.7 .584Preventing retained surgical items 340 61.5 1,545 61.8 .890Preventing medication errors 238 43.0 1,096 43.8 .731Preventing failures in instrument reprocessing 239 43.2 1,030 41.2 .383Preventing pressure injuries 228 41.2 1,002 40.1 .618Preventing specimen management errors 185 33.5 893 35.7 .313Preventing surgical fires 171 30.9 910 36.4 .015Preventing perioperative hypothermia 158 28.6 799 32.0 .120Preventing burns from energy devices 135 24.4 672 26.9 .234Responding to difficult intubation/airway emergencies 154 27.8 566 22.6 .009Preventing venous thromboembolism 113 20.4 461 18.4 .277

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

the nurse. The higher the educational level of the

nurse, the more likely the nurse was to identify

that pressure injuries were a priority. Nurses with

advanced degrees more often identified specimen

management errors to be a priority. Nurses with

associate degrees more often identified respond-

ing to difficult intubation/airway emergencies to

be a priority (Table 8).

DISCUSSION OF THE TOP 10 PATIENTSAFETY ISSUES

Based on these findings, we can identify the top

patient safety issues faced by perioperative nurses

and provide resources to assist nurses with these

issues. The issues identified are similar but vary

among practice settings. Resources that can help

nurses address these issues are available from

AORN Journal j 411

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

AORN, The Joint Commission, and a variety of

other organizations interested in promoting peri-

operative patient safety (Table 9).

1. Preventing Wrong Site/Procedure/Patient Surgery

The National Quality Forum considers wrong site/

procedure/patient surgery to be a serious reportable

event.8 In 2011, 152 wrong site/procedure/patient

events were reported to The Joint Commission,9

making it the second most frequently reported

sentinel event.10 In our study, 68.6% of nurses

rated preventing wrong site/procedure/patient

surgery as one of the five highest priorities. More

nurses working in community and rural hospitals

and ASCs identified this issue than any other, as

did nurses working in hospitals with fewer than

200 beds. This was identified more than any issue

by nurses working in all five regions of the country.

Clearly, preventing wrong site/procedure/patient

surgery remains a serious safety issue for peri-

operative nurses across the country. The variability

may reflect the number of resources already al-

located to this issue or the success of current

preventive measures in the practice settings.

If the setting has achieved a moderate or high

degree of success, other safety issues may be

emerging as a higher priority.

2. Preventing Retained Surgical Items

Retained surgical items are also serious reportable

events.8 Retained surgical items are estimated to

occur in one of 5,550 surgeries.11 This was the

most frequently reported sentinel event in 2011,10

with 188 events reported to The Joint Commis-

sion.9 In our study, 61% of nurses rated preventing

retained surgical items as one of the five highest

priorities for perioperative patient safety. For

nurses working in hospitals, this issue was a higher

priority than for nurses working in ASCs. Nurses

working in academic, public, and federal hospitals

identified this as a top safety issue. The larger the

hospital, the more likely the nurse was to identify

this issue. This difference may be a reflection of

412 j AORN Journal

knowledge of a specific event occurring in the

practice setting or of working in a system such as

the Department of Veterans Affairs that evaluates

data across settings.

3. Preventing Medication Errors

Medication errors resulting in death or serious

injury were the ninth most frequently reported

sentinel event to The Joint Commission in 2011.10

The actual number of medication errors that occur

each year is unknown. In our study, approximately

one-third (43%) of nurses identified preventing

medication errors to be a high priority, regardless

of hospital type and size and nurses’ characteristics.

Two-thirds of nurses in ASCs identified this as

a problem. Nurses in ASCs may lack the resources

available from hospital pharmacies and may be

preparing more medications themselves. Clearly,

this is a priority patient safety issue that deserves

attention, particularly in ASCs.

4. Preventing Failures in InstrumentReprocessing

In recent years, thousands of patients have been

offered infectious disease testing after facilities

publicly reported failures in reprocessing flexible

endoscopes.12 Overall, 41% of nurses identified

preventing reprocessing failures to be a high

priority issue. The percentages were similar across

regions of the country. However, nurses working in

ASCs were more likely to identify this issue as

a priority than were nurses working in hospitals.

Nurses in federal hospitals rated this issue as a high

priority more often than nurses working in other

types of hospitals, as did nurses working in smaller

hospitals. One reason for this is likely the efforts

made by the Department of Veterans Affairs to

focus on transparency of reporting adverse events

and implementing comprehensive corrective

actions. In 2011, the Association for the Ad-

vancement of Medical Instrumentation collabo-

rated with the US Food and Drug Administration

to identify priorities to address regarding reproc-

essing medical devices.13

TABLE 9. Resources to Address the Highest Priority Perioperative Patient Safety Issues*

Safety issue Resources

1. Preventing wrong site/procedure/patient surgery

1. AORN, http://www.aorn.orgn Correct Site Surgery Tool Kit, http://www.aorn.org/Clinical_Practice/ToolKits/

Tool_Kits.aspxn Position statement on preventing wrong-patient, wrong-site, wrong-procedure

events, http://www.aorn.org/Clinical_Practice/Position_Statements/Position_Statements.aspx

n Webinars, http://www.aorn.org/Events/Webinars/Webinars.aspx2. Joint Commission, http://www.jointcommission.org3. World Health Organization, http://www.who.int4. Institute for Healthcare Improvement, http://www.ihi.org/Pages/default.aspx5. Agency for Healthcare Research and Quality, http://www.psnet.ahrq.gov6. National Guideline Clearinghouse, http://www.guidelines.gov7. National Quality Forum, http://www.qualityforum.org

2. Preventing retainedsurgical items

1. AORN, http://www.aorn.orgn Recommended practices for prevention of retained surgical items. In: Peri-

operative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:305-321.

n Goldberg JL, Feldman DL. Implementing AORN recommended practices forprevention of retained surgical items. AORN J. 2012;95(2):205-216.

n Steelman VM, Cullen JJ. Designing a safer process to prevent retainedsurgical sponges: a healthcare failure mode and effect analysis. AORN J.2011;94(2):132-141.

2. Joint Commission, http://www.jointcommission.org3. Agency for Healthcare Research and Quality, http://www.psnet.ahrq.gov4. National Quality Forum, http://www.qualityforum.org

3. Preventing medicationerrors

1. AORN, http://www.aorn.orgn Recommended practices for medication safety. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2013:255-293.n Clinical FAQs, http://www.aorn.org/clinicalfaqs/n Webinars, http://www.aorn.org/Events/Webinars/Webinars.aspx

2. Joint Commission, http://www.jointcommission.org3. Institute for Healthcare Improvement, http://www.ihi.org/Pages/default.aspx4. Agency for Healthcare Research and Quality, http://www.psnet.ahrq.gov5. National Quality Forum, http://www.qualityforum.org6. Anesthesia Patient Safety Foundation, http://www.apsf.org7. Institute for Safe Medication Practices, http://www.ismp.org8. US Food and Drug Administration, http://www.fda.gov9. US Pharmacopeia, http://www.uspharmacopeia.com

4. Preventing failures in instrumentreprocessing

1. AAMI, http://www.aami.orgn Reprocessing. 2011 Summit: Priority Issues from the AAMI/FDA Medical Device

Reprocessing Summit. Arlington, VA: AAMI; 2011. http://www.aami.org/meetings/summits/reprocessing/Materials/2011_Reprocessing_Summit_publication.pdf

2. AORN, http://www.aorn.orgn Recommended practices for cleaning and processing flexible endoscopes and

endoscope accessories. In: Perioperative Standards and RecommendedPractices. Denver, CO: AORN, Inc; 2013:473-484.

(table continued)

AORN Journal j 413

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

TABLE 9. (continued) Resources to Address the Highest Priority Perioperative Patient SafetyIssues*

Safety issue Resources

n Sterile processing webinar series for ambulatory surgery centers, presented inpartnership with International Association of Healthcare Central Service MaterielManagement. http://www.aorn.org/Events/Webinars/Previously_Recorded_Webinars.aspx

n Clinical FAQs, http://www.aorn.org/clinicalfaqs/3. Joint Commission, http://www.jointcommission.org4. National Guideline Clearinghouse, http://www.guidelines.gov5. ECRI Institute, http://www.ecri.org6. Individual manufacturer’s instructions

5. Preventing pressure injuries 1. AORN, http://www.aorn.orgn Recommended practices for positioning the patient in the perioperative practice

setting. In: Perioperative Standards and Recommended Practices. Denver, CO:AORN, Inc; 2013:425-443.

2. National Guideline Clearinghouse, http://www.guidelines.gov3. National Quality Forum, http://www.qualityforum.org4. Wound Ostomy and Continence Nurses Society, http://www.wocn.org

6. Preventing specimenmanagement errors

1. AORN, http://www.aorn.orgn Recommended practices for the care and handling of specimens in the peri-

operative environment. In: Perioperative Standards and Recommended Prac-tices. Denver, CO: AORN, Inc; 2013:323-329.

2. Department of Veterans Affairs National Center for Patient Safetyn The Basics of Healthcare Failure Mode and Effect Analysis. Washington, DC:

Veterans Health Administration; 2001. http://www.patientsafety.gov/SafetyTopics/HFMEA/FMEA2.pdf

7. Preventing surgical fires 1. AORN, http://www.aorn.orgn Fire Safety Tool Kit, http://www.aorn.org/Clinical_Practice/ToolKits/Tool_Kits.aspxn Webinars, http://www.aorn.org/Events/Webinars/Webinars.aspx

2. Anesthesia Patient Safety Foundation, http://www.apsf.org3. ECRI Institute, http://www.ecri.org4. National Guideline Clearinghouse, http://www.guidelines.gov

8. Preventing perioperativehypothermia

1. AORN, http://www.aorn.orgn Recommended practices for the prevention of unplanned perioperative hypo-

thermia. In: Perioperative Standards and Recommended Practices. Denver, CO:AORN, Inc; 2013:375-386.

n Webinars, http://www.aorn.org/Events/Webinars/Webinars.aspxn Clinical FAQs, http://www.aorn.org/clinicalfaqs/

2. Anesthesia Patient Safety Foundation, http://www.apsf.org3. American Society of PeriAnesthesia Nurses, http://www.aspan.org

n Hooper VD, Chard R, Clifford T, et al. ASPAN’s evidence-based clinical practiceguideline for the promotion of perioperative normothermia: second edition. JPerianesth Nurs. 2010;25(6):346-365.

4. National Quality Forum, http://www.qualityforum.org5. National Guideline Clearinghouse, http://www.guidelines.gov

414 j AORN Journal

April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

TABLE 9. (continued) Resources to Address the Highest Priority Perioperative Patient SafetyIssues*

Safety issue Resources

9. Preventing burns fromenergy devices

1. AORN, http://www.aorn.orgn Recommended practices for electrosurgery. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2013:125-141.2. National Quality Forum, http://www.qualityforum.org3. ECRI Institute, http://www.ecri.org4. Individual manufacturer’s instructions

10. Responding to difficultintubation/airway emergencies

1. American Society of Anesthesiologists, http://www.asahq.org2. American Association of Nurse Anesthetists, http://www.aana.com3. Anesthesia Patient Safety Foundation, http://www.apsf.org4. National Guideline Clearinghouse, http://www.guidelines.gov

* All web sites accessed February 7, 2013.

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

5. Preventing Pressure Injuries

More than one million people develop pressure

ulcers each year.14 Unique patient risk factors,

coupled with complex positioning and long surgical

procedures, place surgical patients at increased risk.

Overall, preventing pressure injuries was identified

as a priority by 40% of nurses. This was a higher

priority for nurses working in hospitals than ASCs

and for nurses working in academic hospitals,

larger hospitals, and the Northeast and Midwest.

The acuity of patients and longer duration of

surgeries in academic hospitals may explain this

difference. These hospitals may also have nurses

dedicated to identifying and treating pressure in-

juries. The resources to help nurses prevent OR-

associated pressure injuries are limited. There is

no valid assessment tool to identify patients at

risk for OR-associated pressure injuries. An AORN

task force is currently developing a risk assessment

tool for this purpose. At the local level, imple-

mentation of electronic documentation systems

allows hospitals to identify risk factors and use this

information as a foundation for corrective action.

6. Preventing SpecimenManagement Errors

No national databases provide us with evidence

about the incidence of specimen errors. However,

in a study at a large East Coast hospital, 91 surgical

specimen errors were found in a six-month period.15

If similar rates of error occur in other hospitals

and ASCs, this problem is clearly one that should

be addressed.

Prevention of specimen management errors was

identified by 35% of nurses to be a high priority.

The percentages were similar across setting or type

of hospital. However, nurses working in larger

hospitals (ie, � 100 beds) were more concerned

with this issue than nurses in smaller hospitals. This

difference may reflect the complexity of surgeries

performed in the setting and the number of speci-

mens per procedure. Nurses with advanced educa-

tion were more likely to rate this a high priority

than nurses with less education. This difference

may reflect the job role of the nurse. Nurses with

advanced education may be more likely to be

working in managerial roles and be more knowl-

edgeable about incidents that have occurred in the

setting. Few resources are available to help nurses

prevent specimen errors. This issue could be ex-

plored more thoroughly through a prospective risk

assessment, such as a Healthcare Failure Mode and

Effect Analysis.16 By identifying potential failures

and their causes, this tool facilitates prioritization

of preventive measures.

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April 2013 Vol 97 No 4 STEELMANdGRALINGdPERKHOUNKOVA

7. Preventing Surgical Fires

The ECRI Institute estimates that there are between

550 and 600 surgical fires each year in the United

States.17 Preventing surgical fires was rated a high

priority by one-third of respondents, regardless of

practice setting, region of the country, and char-

acteristics of the nurse. This is likely because of the

seriousness of outcomes should a fire occur. There

are many resources to assist nurses in preventing

and responding to surgical fires.

8. Preventing Perioperative Hypothermia

Although the adverse effects of perioperative

hypothermia have been well documented since

the early 1990s, no national database exists to

report the number of patients who experience

hypothermia during surgical procedures. A litera-

ture review published in 2012 by Knaepel puts the

incidence of surgical patients experiencing hypo-

thermia as high as 70%.18 A practice guideline

by American Society of PeriAnesthesia Nurses

recognizes the significance of hypothermia but does

not identify incidence.19 Overall, slightly less than

one-third of nurses in our study rated prevention

of perioperative hypothermia to be a high priority,

regardless of type of practice setting, type and

size of hospital, or region of the country. This

did vary by educational preparation of the nurse.

Diploma-prepared nurses were more likely to

identify this as an issue than other nurses. The

impact of national quality programs such as the

Surgical Care Improvement Project20 may have

decreased the need to identify this issue in top

ranking across the practice settings. There are

several resources to address the issues of hypo-

thermia both from regulatory agencies and

specialty organizations.

9. Preventing Burns From Energy Devices

The most common type of electrosurgery injury has

been identified as resulting from direct application

of current to tissue away from the active electrode,

otherwise known as direct coupling.21 More than

one-fourth of nurses identified prevention of burns

416 j AORN Journal

from energy devices to be a priority issue, regard-

less of hospital type and size or region of the

country. In ASCs, this issue was more likely to

be a priority than in hospitals. The reason for this

difference may be the high use of a variety of

energy devices in ASCs, although more research is

needed to determine the actual reasons. Several

resources are available to assist with developing

strategies to prevent burns from energy devices.

Resources from individual energy device manu-

facturers are available for specific devices.

10. Responding to Difficult Intubation/Airway Emergencies

The 10th priority patient safety issue identified

was responding to difficult intubation/airway

emergencies. The Pennsylvania Patient Authority

recognized management of difficult airway as

a safety issue in 2009 and reported 38 occurrences

in a total of 448 reports of anesthesia-related

complications.22 A higher percentage of nurses in

ASCs identified this issue as a high priority than

those working in hospitals, and nurses working in

smaller hospitals were more likely to identify this

issue than those working in larger hospitals. This

may be because hospitals have more resources and

time to conduct preanesthesia evaluations before

initiation of anesthetic care and more resources to

respond to airway emergencies when they occur

than ASCs. It was interesting to note that nurses in

the Southwest and West identified this issue more

often. More information is needed to truly under-

stand this difference. Associate degree-prepared

nurses more often identified responding to difficult

intubation/airway emergencies to be a priority

than nurses with diplomas or with higher levels

of education. This may reflect the greater number

of associate degree-prepared nurses working in

staff nurse roles who identified this issue because

of the severity of this type of event.

LIMITATIONS

This study has several limitations. First, the sample

was drawn from the AORN membership database.

PERIOPERATIVE PATIENT SAFETY ISSUES www.aornjournal.org

The database had 37,000 members with active

email addresses. The survey screened for retired

nurses and those working for industry. Although

we could not determine the number of potential

respondents, our response rate appears low. We

do not have information about all perioperative

nurses in the United States and cannot verify that

respondents represent that entire group. However,

the most frequently reported job roles and ed-

ucational preparation were the same as those in

the AORN database.7 Second, because unique

identifiers were not collected, it was possible for

a nurse to respond more than once to the survey.

However, there was no incentive to do so, and the

large sample would diminish the effect of this in

the analysis.

SUMMARY

This survey identifies patient safety issues faced

by perioperative nurses. Differences were noted

in the priorities identified by nurses working in

hospitals versus ASCs. This difference supports

anecdotal feedback we have received from nurses

working in ASCs that their setting is different and

different resources are needed. Resources have

been identified to assist nurses in addressing

safety issues. These resources provide direction

for educators when reviewing orientation mate-

rials, developing new educational programs, and

evaluating competencies, but, more importantly,

provide a foundation for allocation of resources.

Nurses in leadership positions should use this

information to prioritize quality improvement

initiatives in their practice setting. The gaps in

available resources can be used at the national

level to prioritize future initiatives, including de-

velopment of a validated assessment tool for risk

of OR-associated pressure injuries. Once risk fac-

tors are identified, preventive measures can be

designed to prevent these injuries. The lack of

data about the incidence of specimen management

errors should be addressed through a prospective

risk assessment.

Editor’s note: This study was funded by the AORN

Foundation. A follow-up to this article, titled “Top

10 patient safety issues: what more can we do?”

that includes targeted recommendations for further

improving perioperative safety will be published in

the June 2013 issue of the AORN Journal.

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418 j AORN Journal

Victoria M. Steelman, PhD, RN, CNOR,

FAAN, is an assistant professor, College of

Nursing, The University of Iowa, Iowa City. Dr

Steelman has no declared affiliation that could

be considered a potential conflict of interest in

the publication of this article.

Paula R. Graling,DNP, RN, CNOR, is a clinical

nurse specialist, Inova Fairfax Hospital, Falls

Church, VA. Dr Graling has no declared affili-

ation that could be considered a potential conflict

of interest in the publication of this article.

Yelena Perkhounkova, PhD, is a statistician,

College of Nursing, The University of Iowa, Iowa

City. Dr Perkhounkova has no declared affilia-

tion that could be considered a potential conflict

of interest in the publication of this article.