top 10 patient safety issues

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CONTINUING EDUCATION

Top 10 Patient Safety Issues:

What More Can We Do?VICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN;

PAULA R. GRALING, DNP, RN, CNOR 3.9www.aorn.org/CE

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Event: #13517

Session: #0001

Fee: Members $23.40, Nonmembers $46.80

The contact hours for this article expire June 30, 2016.

Purpose/Goal

To enable the learner to proactively intervene to mitigate risks

for the top perioperative patient safety issues.

Objectives

1. Describe the top patient safety issues identified in an

AORN member survey.

2. Identify methods to mitigate the risks of injury posed by

the identified patient safety issues.

Accreditation

AORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Centers

Commission on Accreditation.

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This program meets criteria for CNOR and CRNFA recertifi-

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AORN is provider-approved by the California Board of

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Conflict of Interest Disclosures

As a consultant of RF Surgical Inc, Dr Steelman has declared

an affiliation that could be perceived as posing a potential

conflict of interest in the publication of this article. Dr Graling

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

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

Perioperative Education. Ms Holm and Ms Bakewell haveno declared affiliations that could be perceived as posing

potential conflicts of interest in the publication of this article.

Sponsorship or Commercial Support

No sponsorship or commercial support was received for this

article.

Disclaimer

AORN recognizes these activities as continuing education

for registered nurses. This recognition does not imply that

AORN or the American Nurses Credentialing Center approves

or endorses products mentioned in the activity.

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Top 10 Patient Safety Issues:

What More Can We Do?VICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN;

PAULA R. GRALING,DNP, RN, CNOR 3.9

www.aorn.org/CE

ABSTRACT

A 2012 survey of AORN members identified the top 10 safety issues reported by

perioperative nurses. These nurses are in a unique position to understand the errors and

the unreported near misses that occur in the OR. For each of the top-rated safety issues

that RNs identified, we discuss the evidence of risk and contributing factors and make

targeted recommendations for further improvement in perioperative safety with

the goal of mitigating risk and improving patient outcomes. AORN J97 (June 2013)

680-698. AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.04.012

Key words: medication errors, patient safety, pressure ulcer, surgical errors.

During the past decade, medical errors and

adverse events in health care have become

a national priority, resulting in numerous

programs to improve the safety of patient care.1-4

However, a recent research study showed that ad-

verse events occur at an alarming rate, affecting

30% of hospitalized adult patients5; other near

misses are unreported. Many adverse events and

near misses occur during care of the surgical pa-

tient. The complexities of the surgical procedure,

anesthesia, technology, and teamwork increase

patient risk during the perioperative experience.

Perioperative RNs are in a unique position to

understand the adverse events and unreported near

misses that occur every day. In December 2011, we

surveyed AORN members to determine what they

consider the highest-priority patient safety issues

that currently need to be addressed. We received

3,137 usable completed surveys.6 For the top 10

safety issues identified, we solicited anecdotal re-

ports from nurses that provided us with a more

thorough understanding of factors that contribute

to these safety issues and that allowed us to develop

targeted recommendations for improvement. The

purposes of this paper are to

n review the top 10 patient safety issues identifiedby perioperative RNs (Table 1);

n describe the overall seriousness of these issues;

n identify contributing factors; and

n make recommendations based on this evidence

for targeted interventions to promote patient

safety and decrease errors.

1. PREVENTING WRONG SITE/PROCEDURE/PATIENT SURGERY

More than two-thirds of the perioperative nurses

who responded to the survey rated preventing wrong

site surgery as one of the five highest priorities to

address.6 This may be somewhat surprising because

of the longevity of national initiatives to prevent this

never event. In 1998, The Joint Commission first

recommended marking the surgical site and using

a verification checklist.7 Wrong site/procedure/

patient surgery is estimated to occur 40 times per

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week8 and remains the second most commonly re-

ported sentinel event to The Joint Commission.9

The Joint Commission has identified risk points

in processes where wrong-site surgery can be pre-

vented, including scheduling errors, verification

errors, distractions/rushing, inconsistent site mark-

ing, no safety culture, and time-out errors.8 Re-

searchers observing procedures in eight facilitiesin Minnesota identified inconsistencies in site

marking (eg, no mark, mark made in the OR,

marks that were obscured or ambiguous, marks

made without referencing source documents) and

time-out procedures (eg, no time out, not ceasing

activity, using memory rather than documents,

surgeon not present) as contributing factors to

wrong site surgery.10

What More Can We Do?Based on this evidence, we can make recommen-

dations for further action to help prevent wrong site/

procedure/patient surgery. First, to improve the ac-

curacy of information on the surgery schedule, peri-

operative nurses should collaborate with scheduling

personnel from surgeons offices to implement a

checklist for scheduling surgery. The Pennsylvania

Patient Safety Authority (PPSA) has a checklist for

office schedulers11 and OR schedulers12 that can be

modified for facility use.

The preoperative nurse should verify that all

necessary documents (eg, consent, history and

physical examination report, orders, OR schedule)

are available, and the surgeon should verify and

mark the site using these documents. The patient

should not be transferred into the OR until this

is complete.

Next, nurses should

n strictly enforce adherence to the time out,

n avoid workarounds that decrease the effective-

ness of this safety measure, and

n not tolerate deviations or lack of engagement of

team members.

We must place a hard stop on interruptions dur-

ing the time out and should not rely on memory

during this verification. It is essential that nurses

speak up when they are concerned about any safety

issue. When more than one procedure is being

performed by the same surgeon, the site and later-

ality should be confirmed before each procedure.

The entire time-out process should be repeated

when there is a change of surgeon.8

The PPSA has identified best practices for reli-able performance of the Universal ProtocolTMbased

on an analysis of near misses and errors.10 For spinal

surgery, best practices include intraoperative im-

aging using markers that do not move and seeking

a radiologists interpretation of the image in addi-

tion to the surgeons.

A multidisciplinary team should review and

revise facility policies and procedures using both

The Joint Commission and PPSA recommendations

as a framework for operationalizing the UniversalProtocol. The rationale for these recommendations

is depicted in The evidence base for the princi-

ples for reliable performance of the Universal Pro-

tocol.13 This document reviews the causes of

wrong site/procedure/patient surgery and near

misses as well as evidence showing how errors

were detected before the incision (see Supple-

mentary Figure at http://www.aornjournal.org).

TABLE 1. Top 10 Safety Issues Identified by

Perioperative RNs (N [ 3,137)1

Safety issue %

1. Preventing wrong site/procedure/patient surgery 692. Preventing retained surgical items 61

3. Preventing medication errors 43

4. Preventing failures in instrument reprocessing 41

5. Preventing pressure injuries 40

6. Preventing specimen management errors 35

7. Preventing surgical fires 35

8. Preventing perioperat ive hypothermia 31

9. Preventing burns from energy devices 26

10. Responding to difficult intubation or airway

emergencies

23

1. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety

issues identified by perioperative nurses.AORN J. 2013;97(4):402-418.

AORN Journal j 681

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Furthermore, the quality management program

should include a comparison of policies and pro-

cedures (ie, gap analysis) with recommendations

of both The Joint Commission and the PPSA.

In June 2004, AORNdwith the support of The

Joint Commission, the World Health Organization,

and the Council on Surgical and Perioperative

Safetydinitiated National Time Out Day to sustain

and promote progress in preventing wrong site/

procedure/patient surgery.14 Perioperative nurses

should use this annual campaign as a mechanism to

raise awareness within their facilities, to reenergize

efforts, and to engage other disciplines regarding

the Universal Protocol process.

2. PREVENTING RETAINED SURGICALITEMS

Sixty-one percent of the nurses who were surveyed

identified preventing retained surgical items to be

a high priority.6 Retained items are estimated to

occur in 1 in 5,550 surgeries.15 The National Quality

Forum considers retained surgical items to be se-

rious reportable events,16 and this was the sentinel

event most frequently reported to The Joint Com-

mission for the past three years (ie, 133, 188, and

115 events voluntarily reported).9

A health care failure mode and effect analysis

identified 43 high-risk failures that can occur dur-

ing management of sponges, providing insight into

how these events can occur and where controls

are needed for successful prevention. The most

frequently identified causes of these potential fail-

ures include distraction, multitasking, not following

the facilitys count procedure, and time pressure

(Table 2).17

What More Can We Do?

Based on this evidence, we can make recommen-

dations for prevention of retained surgical items.

First, perioperative nurses should minimize dis-

tractions and multitasking while managing counted

items (eg, adding and removing items from the

sterile field, counting). Before counting, the nurse

should alert the team that the count will be starting.

This allows other urgent tasks to be prioritized.

Perioperative nurses also should actively enforce

the facilitys procedures for managing counted

items. Unfortunately, distraction, multitasking,

and time pressure are inherent in the work in anOR and are difficult to control.

AORNs Recommended practices for preven-

tion of retained surgical items was significantly

revised in 2011 and includes recommendations

focusing on a multidisciplinary approach to pre-

vention. The recommendations state that peri-

operative staff members may consider the use of

adjunct technologies to supplement manual count

procedures.18(p314) Adjunct technology provides

the needed control for the causes of potential fail-ures in managing surgical sponges (eg, distraction,

multitasking, time pressure).

Nurses should participate in evaluating and

selecting adjunct technology, and they should

consider the ability of technological devices to

detect failures in managing sponges. The cost of

purchasing adjunct counting technology may be

offset by the reduction in OR time spent resolving

TABLE 2. Causes of High-Risk Failures in

Preventing Retained Surgical Sponges1

n Distraction

n Multitasking

n Not following procedure

n Time pressure

n Emergency

n The surgeon continues to close the wound during the

count

n The RN circulator is unable to see the item from his or

her location during the count

n Dressings are unwrapped during the surgical

procedure

n Mixing trash with sponges and other counted items

n Pockets for separating sponges are stacked and not

all visible

n

The scrub person counts too fastn Sponges are in use during the count

1. Steelman VM, Cullen JJ. Designing a safer process to prevent

retained surgical sponges: a health care failure mode and effect

analysis. AORN J. 2011;94(2):132-141.

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incorrect counts, intraoperative radiographs for

incorrect counts, and the additional patient care

related to retained items. A multidisciplinary

team should review and revise facility policies

and procedures to reflect the new AORN recom-

mendations.

3. PREVENTING MEDICATION ERRORS

Overall, 43% of all nurses surveyed and two-thirds

of nurses working in ambulatory surgery centers

(ASCs) identified preventing medication errors to

be a high priority.6 The higher percentage in ASCs

likely reflects the lack of available resources in that

setting compared to the resources that are typically

provided by hospital pharmacies. Although the

actual number of medication errors that occur

each year is unknown, medication errors resulting

in death or serious injury were the ninth most

frequently reported sentinel event to The Joint

Commission in 2012.9 The PPSA reviewed 502

medication error reports from ASCs between 2004

and 2010.19 The most common types of errors

reported were medication omission, wrong medi-

cation, monitoring error, and administering a med-

ication for which there was a documented allergy.

The most common routes of administration asso-

ciated with errors were IV, ophthalmic, and oral.

The most common classes of medications associ-

ated with errors were antibiotics (33.9%), local

anesthetics (8%), corticosteroids (4.6%), opioid

analgesic combinations (4.6%), benzodiazepines

(4.2%), and nonsteroidal anti-inflammatory agents

(3.8%). The most common medications associ-

ated with errors identified were cefazolin (15.3%),

vancomycin (4%), and midazolam (4%).

Some of the issues involved with perioperative

medication safety include

n adult versus pediatric dosing,

n lack of standardization,

n unnecessary variability of doses,

n verbal orders,

n lack of labeling and communication about

medications,

n use of surgeons preference cards for preparing

medications, and

n tolerance of non-approved abbreviations.

In ASCs, specific contributing factors include

communication failures or overlooking preopera-tive orders, choosing the wrong ophthalmic medi-

cation, failing to label medications on the sterile

field, and relying on color coding rather than

medication labels.19


Based on this evidence, we recommend strategies to

improve medication safety in perioperative settings

that require collaboration with surgeons, anesthesia

professionals, and pharmacists for implementation.First, we should separate medications for adults,

pediatric patients, and neonates. Other recommen-

dations include

n reviewing and revising code carts, which entails

n stocking a separate pediatric code cart,

n color coding the different drawers based on

child size,20 and

n stocking a separate neonatal medication box

for the code cart if neonates are treated in the

facility;

n providing medication reference sheets with IV

titration dosing guides for all medications in all

concentrations available; and

n standardizing medication trays within the

facility, including;

n stocking the separate trays with appropriate

doses for the patient receiving care and

n standardizing medication trays across facili-

ties in the geographical area to provide

consistency for anesthesia professionals whowork in more than one setting.21

We also need to standardize the doses that are

used for medications such as epinephrine in irri-

gation and tumescent solutions. When pharmacy

personnel are available, they should mix medica-

tions under a hood if the medication is intended for

use on the sterile field. This service minimizes

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distractions and contamination when medications

are being mixed and dispensed onto the sterile field.

We need to make a concerted effort to minimize

verbal orders by implementing standard order sets

and implementing briefings with the surgeon before

each procedure. We should no longer use surgeon

preference cards to identify doses because many

surgeons are actually unaware of what information

is on the preference cards. Instead, we should re-

place this practice with the use of physician order

sets. We need to strictly enforce labeling of medi-

cations and solutions that are removed from their

original containers and communicating with the

surgeon when handing off medications. We need

to strictly practice the seven rights of medication

safety: right patient, medication, dose, time, route,

reason, and documentation.22 Lastly, we need

to enforce a hard stop on using non-approved

abbreviations.

4. PREVENTING FAILURES IN

INSTRUMENT REPROCESSING

Overall, 41% of the perioperative nurses identified

preventing failures in instrument reprocessing to

be a high priority for action; 48% of nurses working

in ASCs and 59% of nurses in federal hospitalsrated this issue a high priority.6 These differences

likely reflect the limited resources in ASCs com-

pared to hospitals and a large federal initiative in

the Veterans Administration to improve endoscope

reprocessing.23 Reporting of reprocessing failures

is not federally mandated, so the extent of this

problem is unknown and errors have gone unre-

ported. In an effort to achieve transparency in

recent years, more than 15,000 patients were of-

fered infectious disease testing after failures inreprocessing of endoscopes.23-25

Anecdotal reports from perioperative nurses

indicate that reprocessing of instruments is a com-

mon practice in ORs and that this reprocessing is

frequently performed in a manner that is inconsis-

tent with national recommendations from the

Association for the Advancement of Medical

Instrumentation,26 AORN,27 and the Centers for

Disease Control and Prevention/Healthcare Infec-

tion Control Practices Advisory Committee.28

Contributing factors likely include a lack of cen-

tralized oversight, a lack of training, inadequate

quality management, a lack of administrative sup-

port to resolve inadequate quantities of instrumen-

tation, and the complexity of managing vendor trays.


Perioperative nurses should collaborate with oth-

er departments, including sterile processing and

infection control, to develop and implement a

facility-wide program for reprocessing. This

program should include establishing centralized

oversight, ensuring involvement of sterile process-ing department personnel in instrument purchasing

decisions, identifying locations where reprocessing

is permitted, identifying processes used in the fa-

cility for managing reusable medical devices that

require reprocessing, ensuring personnel compe-

tency, requiring documentation of reprocessing

steps, and ensuring ongoing quality controls and

monitoring.

Centralized oversight is important to ensure that

processes throughout the facility meet expectedstandards. Centralized oversight also establishes

accountability for processes that are in place. Sterile

processing department personnel should be con-

sulted in instrument purchasing decisions to

ensure that

n manufacturers instructions for use (IFU) are

reviewed,

n manufacturers IFU are consistent with facility

reprocessing procedures, and

n the technology and accessories to effectively

reprocess instruments are either available or

included in the purchase.

Instruments should only be decontaminated in

a location that

n is designed for this purpose,

n has a negative pressure air-handling system,

n is equipped with a washer decontaminator,

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n is equipped with a variety of tools necessary to

effectively clean instruments in a manner

consistent with the manufacturers IFU, and

n is stocked with personal protective equipment to

minimize exposure to contaminants.

Furthermore, manufacturers IFU should be readily

available in the decontamination area and consis-

tently followed. Trays of instruments should be

cleaned in a mechanical washer decontaminator

unless contraindicated by the IFU.

Reprocessing instruments in the OR is high risk

because time pressures encourage personnel to

circumvent the rigor required for effective reproc-

essing. Personnel may feel pressure to cut corners

in the cleaning process or may wear OR scrubs intothe decontamination area and then back into an OR.

Adequate training for and competency evaluation

of the various people who might be asked to per-

form the reprocessing is difficult to achieve.

AORN recommends that immediate use steam

sterilization (IUSS) only be used when there is

insufficient time to sterilize in a wrapped tray or

container for instruments that are subjected to the

same decontamination standards as other instru-

ments and not be used in lieu of an adequateinstrument inventory.27 Immediate use steam ster-

ilization should only be performed if

n the manufacturers IFU include instructions

for IUSS,

n the IFU are available and followed,

n items are placed in a container validated and

cleared by the US Food and Drug Administra-

tion for IUSS,

n

the container manufacturers IFU are followed,n measures are taken to prevent contamination

during transfer to the sterile field, and

n the sterilized items are not stored.27

Instrument reprocessing should only be per-

formed by trained personnel who have demonstrated

competencies in reprocessing the variety of devices

used in the clinical setting. State regulations must

be strictly followed. For example, the state of New

Jersey requires that sterile processing department

technicians be certified to demonstrate reprocessing

competencies,29 and several other states have sim-

ilar bills in process. At a minimum, staff member

competency should be evaluated and documented

for each type of surgical instrument and every type

of flexible endoscope that is reprocessed in the

clinical setting.

Ongoing quality control monitoring should be

conducted on every reprocessing cycle. This quality

control requires comprehensive documentation to

allow instruments to be traced to individual patients.

Each detail of reprocessing should be documented,

and routine audits of compliance with procedures

and IFU should be performed. An ongoing quality

improvement program should be in place to evaluate

the reprocessing of instruments between procedures

and any incidents of noncompliance with national

recommendations. This type of program includes

setting clear expectations of appropriate reprocess-

ing; ensuring competency of personnel; reviewing

internal data; and implementing corrective actions

when necessary, such as purchasing additional in-

struments or retraining personnel.

In 2011, the Association for the Advancementof Medical Instrumentation and the US Food and

Drug Administration convened a summit to discuss

issues and priorities for action related to reproc-

essing. This summit reinforced the basics of in-

strument reprocessing in health care facilities

(Table 3).26

Issues related to failures in instrument re-

processing have been discussed for decades.

However, recent events23-25 have raised the level

of concern and instilled a sense of urgency foraction and an incentive for change. Perioperative

nurses should take advantage of this sense of

urgency to garner administrative support to fa-

cilitate improvements in their practice settings,

including support for allocating the resources

necessary to come into compliance with national

recommendations.

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5. PREVENTING PRESSURE INJURIES

Overall, 40% of the nurses surveyed identified

preventing pressure injuries as a high priority,

particularly nurses in large (53%) or academic

hospitals (55%) as opposed to ASCs (17%).6 This

is likely because of the differences in procedure

duration in these settings.

More than one million people develop hospital-

acquired pressure ulcers each year,30 and 25% of

these injuries are associated with the OR.31 The

National Quality Forum considers stage III or IV

health care-acquired pressure injuries to be serious

reportable events.16

Pressure injuries are caused by inadequate tissue

perfusion, usually over a bony prominence, which

results from pressure or a combination of pressure

and shearing. The long duration of immobility dur-

ing surgical procedures places patients at increasedrisk. Impaired circulation from peripheral vascular

disease and hypotension during surgery also de-

crease perfusion. Furthermore, devices used intra-

operatively to prevent blood flow to the surgical site

(eg, tourniquet, vascular clamps) prevent blood flow

to distal tissue (eg, heels).

The heel is the most common location of the more

serious pressure injury (ie, deep tissue injury).32

Concentration of pressure on the small surface of

the heel, coupled with impaired circulation, makes

this tissue especially vulnerable to injury during

surgery. The incidence of heel pressure injuries

has been found to be 17% after orthopedic33 and

29.5% after cardiac surgery.34

What More Can We Do?Our efforts to prevent intraoperatively acquired

pressure injuries start with an adequate preoperative

skin assessment. Nurses should be knowledgeable

about the risk factors for and the pathophysiology

of pressure injuries as well as the effectiveness

of pressure-dispersing surfaces. Nurses should use

these devices appropriately to disperse pressure

on affected body parts. When planning care for

a severely debilitated patient or someone with a

preexisting pressure injury, perioperative nursesshould consult with a wound ostomy specialist to

tailor positioning for the individual patient.

Next, patients should be safely transferred and

positioned in a manner that prevents shearing. For

example, for a supine-to-supine transfer of a patient

weighing more than 157 lb, personnel should use

a mechanical lifting device.35 When repositioning

the patient into lithotomy, an adequate number of

TABLE 3. Key Recommendations for Reprocessing

1. Perform cleaning and disinfection/sterilization as separate steps before each patient use and in compliance with

manufacturers instructions for use (IFU).

2. Have the IFU and all accessories necessary to comply with the instructions available in all reprocessing locations.

3. Establish an interdisciplinary committee (eg, OR, materials management, health care technology management, endoscopy,

infection control) to address priority issues.

4. Share lessons learned from other facilities and establish transparency in notifying patients when they are exposed to

reprocessing failures.

5. Establish a reprocessing program, including clear accountability and policies and procedures.

6. Know the current standards, recommended practices, and IFU regarding reprocessing.

7. Involve sterile processing department personnel in instrument purchasing decisions to verify that new instruments can be

safely and effectively reprocessed.

8. Separate materials storage and distribution from reprocessing; develop job descriptions.

9. Train personnel in reprocessing and evaluate competencies regularly.

10. Audit compliance with policies and procedures on a regular basis.

Adapted with permission from Priority Issues from the AAMI/FDA Medical Device Reprocessing Summit. Arlington, VA: Association for the Advancement ofMedical Instrumentation (AAMI); 2011. http://www.aami.org/meetings/summits/reprocessing/Materials/2011_Reprocessing_Summit_publication.pdf.

Accessed April 8, 2013.

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personnel are required to lift the patients buttocks

rather than dragging the patient into position.

Then the perioperative nurse must ensure that

pressure on the patients heels is eliminated. The

National Pressure Ulcer Prevention Advisory Panel

(NPUPAP) and the European Pressure Ulcer Ad-

visory Panel (EPUAP) recommend elevating the

heels completely, which redistributes the weight

of the leg along the calf, without putting all the

pressure on the Achilles tendon.36 The knee should

be flexed slightly, because hyperextension can

cause occlusion of the popliteal vein, which in-

creases the potential for deep vein thrombosis.37,38

This expectation should be clarified in facility

policies and procedures.

Lastly, perioperative nurses should collaborate

with wound ostomy nurses to review internally

collected data about pressure injuries and take

corrective action based on this evidence. The pres-

sure injury risk assessment tools that are currently

available do not focus on potential intraoperative

risk factors, such as positioning and duration of

surgery. AORN has established a task force that

is developing a risk assessment tool for intraoper-

atively acquired pressure injuries. When a valid and

reliable tool to assess risk is available, perioperativenurses can use the collective data from electronic

documentation systems to test the effectiveness of

strategies for preventing pressure injuries.

6. PREVENTING SPECIMEN MANAGEMENT

ERRORS

Thirty-five percent of the nurses responding to our

survey identified prevention of specimen manage-

ment errors to be a high priority for action.6 Nurses

working in larger hospitals (ie, 100 beds) prior-itized this issue more often (34.8% to 39.3%) than

nurses in smaller hospitals (28.6%). This difference

may reflect the complexity of surgeries performed

and the number of specimens per procedure in the

large-hospital setting.

Specimen management errors are not publicly

reported; however, researchers in a large East Coast

hospital studied surgical specimen errors during

a six-month period.39 They found the incidence of

surgical specimen identification errors (eg, spec-

imen not labeled; empty container; incorrect later-

ality, tissue site, patient; no patient name; no tissue

site) was 4.3 in 1,000, and more than half were

associated with biopsy procedures.

Specimen management errors are very serious

and can lead to a delay in care, the need for reop-

eration, a failure to receive appropriate therapy, and

a lack of confidence in the quality of the facility

and the providers delivery of patient care. Anec-

dotal reports from perioperative nurses indicate that

contributing factors may include communication

failures in the OR, time pressure, interruptions, and

using preprinted labels from a previous patient.


Preventing specimen management errors requires

ensuring communication in the OR, labeling of

specimens accurately, eliminating multitasking

during specimen management, and ensuring veri-

fication before sending the specimen out of the

OR. Communication about specimens should be

included in a preoperative briefing with the sur-

geon. AORNs Comprehensive Surgical Checklist,

based on recommendations from The Joint Com-mission and the World Health Organization, in-

cludes a briefing and debriefing model that can

be modified for use in the facility (Figure 1).40

By knowing what specimens can be anticipated,

the circulating nurse can minimize the time pressure

for specimen handling during the procedure. Spec-

imens should be labeled with two unique identi-

fiers.3 If preprinted patient labels are used, the nurse

should verify the accuracy of information on each

label as it is used and should ensure that unusedlabels are removed from the room at the end of

the procedure. Multitasking during specimen man-

agement should be avoided. Lastly, a debriefing

with the surgeon at the end of the procedure

should include reviewing the identification of

specimens that were obtained and of the fixative

that was used. Before transferring the specimen

out of the OR, two people should verify the label

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Figure 1. The AORN Comprehensive Surgical Checklist, which includes a briefing, time out, and debriefing to enhance patient saf

the individual practice setting. Copyright 2012, AORN, Inc. All rights reserved. Reprinted with permission .

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and contents, similar to the verification procedure

for blood products.39

Specimen management should be included in the

facilitys quality management programs and should

be investigated through a prospective risk assess-

ment, such as a health care failure mode and effect

analysis.41 This analysis should include all steps

in specimen management, including handling and

processing. By identifying potential failures and

their causes in the practice setting, this tool facilitates

prioritization of additional preventive measures.

7. PREVENTING SURGICAL FIRES

Preventing surgical fires was rated a high priority

by slightly more than one-third of respondents,

regardless of practice setting.6 This is likely be-

cause of the seriousness of related outcomes. The

ECRI Institute estimates that there are between

550 and 650 surgical fires each year in the United

States, and most are associated with the presence of

an oxygen-enriched atmosphere under the surgical

drapes.42

This phenomenon occurs when oxygen is de-

livered through an open source, such as nasal prongs

or an uncuffed endotracheal tube. Recent anecdotal

reports indicate that the use of antimicrobial prepagents containing alcohol has increased dramati-

cally. Use of these agents, accompanied by time

pressure, increases the risk of surgical fires. Often,

there is inadequate communication among members

of the surgical team about the risk of fire, so the

person using the ignition source may be unaware

of an open oxygen source or alcohol fumes.


The US Food and Drug Administration has devel-oped comprehensive recommendations for prevent-

ing surgical fires.43 We recommend implementing

these recommendations as part of a fire safety

program:

n provide multidisciplinary training and drills,

n perform a fire risk assessment before making

the initial incision,

n communicate about the use of an open source of

oxygen or flammable prep agent before making

the incision,

n allow ample time for flammable prep agents to

dry, and

n holster the electrosurgery pencil when it is not

in use.

Conducting a fire risk assessment is extremely

important and should include aspects uniquely re-

lated to the specific procedure (Table 4). Fire

safety should be openly discussed during the

briefing before every procedure; risks should be

clearly communicated, and actions that should be

taken to mitigate these risks should be discussed.

Because of the seriousness of surgical fires, this

program also should include ongoing monitoring

of compliance. The Fire Safety Tool Kit,44 avail-

able as a free member benefit from the AORN

web site, contains tools to assist in proactively

promoting fire prevention, planning effective re-

sponse strategies, and developing department-

specific policies and protocols to protect patients

and staff members.

8. PREVENTING PERIOPERATIVE

HYPOTHERMIA

Overall, 31% of nurses in our study rated preven-

tion of perioperative hypothermia to be a high

priority.6 Staff nurses and registered nurse first

assistants (RNFAs) were more likely than others

to identify this issue as a problem (35.7% versus

26.5%). This difference might be explained by

the focus of their job responsibilities. Nurses pro-

viding indirect patient care might be focusing on

rates of compliance with reported process perfor-

mance measures and consider this safety issue

to be adequately addressed. Nurses providing

direct patient care may be focusing on individ-

ual patient outcomes and recognize the need for

additional focus.

All anesthetized surgical patients are at risk

for becoming hypothermic.45 Perioperative hypo-

thermia is a safety issue because hypothermia

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n increases the risk of a postoperative surgical site

infection,46

n triples the risk of a morbid cardiac event

occurring,47

n causes coagulopathy and the need for

transfusion,48,49

n extends the duration of neuromuscular blocking

agents,50,51 and

n delays recovery.52

No national database exists to report the inci-

dence of perioperative hypothermia; however, a

literature review published in 2012 estimates

the incidence to be as high as 70% of surgical

patients.53 The National Quality Forum has en-

dorsed a process standard for perioperative tem-

perature management,54 originally part of the

Surgical Care Improvement Project (SCIP). This

performance measure requires either the use of

TABLE 4. Preoperative Briefing: Fire Risk Assessment Questions and Elements of Mitigation

1. Is oxygen or nitrous oxide being openly administered (eg, uncuffed endotracheal tube, nasal prongs, mask)?

Mitigation:

n Configure surgical drapes to allow sufficient venting.

n Deliver 5 L/min to 10 L/min of air under the surgical drapes.

n Titrate oxygen to the lowest percent necessary.

2. Is an electrosurgical unit (ESU), a laser, or a fiber-optic light cable being used?

Mitigation:

n Replace the active ESU electrode in the holster when it is not in use.

n Moisten sponges that are in close proximity to the ESU activation site.

n Do not use the active electrode to surgically open a distended bowel.

n Inspect minimally invasive ESU instruments for impaired insulation; remove them from service if they are not intact.

n Remove the active ESU electrode tip before disposing of it into the sharps container.

n Use a laser-resistant endotracheal tube when using a laser during upper airway procedures.

n Place wet sponges or towels around the surgical site.

n Ensure that only the person controlling the laser beam activates the laser.

n

Place the light source in standby mode or turn it off when it is not in use.n Inspect light cables before use and remove them from service if broken light bundles are visible.

3. Is an alcohol-based skin prep or other volatile chemical being used?

Mitigation:

n Prevent pooling of skin prep solutions.

n Remove prep-soaked linens and prepping towels before draping.

n Allow skin prep agents to dry and fumes to dissipate before draping.

n Conduct a skin prep time out to validate that the prepping agent is dry before draping the patient.

n Do not place flammable chemicals (eg, alcohol, collodion) on the sterile field until after the active ESU electrode has been

disconnected.

4. Is the surgical procedure being performed above the xiphoid process?

Mitigation:

n Coat the head and facial hair near the surgical site with water-soluble lubricant to decrease flammability.

n Use an adhesive incise drape.n Do not use the ESU electrode to open the airway (eg, trachea, bronchus).

n Suction the oropharynx deeply before using the ignition source if oxygen is used.

n Stop supplemental oxygen for one minute before using electrosurgery, electrocautery, or a laser for head, neck, or

upper chest procedures.

Adapted with permission from the AORN Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/firesafety. Accessed April 8, 2013.

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active warming (eg, forced-air warming [FAW])

intraoperatively or normothermia within 30 min-

utes before or after the end of anesthesia.54 Un-

fortunately, compliance can be demonstrated even

when using FAW incorrectly and ineffectively.

Factors contributing to inadequate prevention

of perioperative hypothermia include not under-

standing the pathophysiology and the effectiveness

of interventions for prevention, using ineffective

interventions (eg, warmed cotton blankets), using

FAW inappropriately, and focusing on com-

pliance with the SCIP process measure rather than

patient outcomes.


We recommend conducting multidisciplinary ed-

ucation about the pathophysiology of perioperative

hypothermia and the effectiveness of interventions,

using preoperative as well as intraoperative active

warming, using prewarmed IV fluids, and including

measurement of patient outcomes as part of a quality

management program. Patients should be actively

warmed preoperatively for at least 30 minutes to

minimize the temperature gradient between the core

and peripheral tissues and to prevent redistribution

hypothermia on induction of anesthesia.55 Preoper-ative warming with warmed cotton blankets is inef-

fective at preventing hypothermia56 and should be

replaced with active warming in the preoperative

area that is restarted immediately on arrival in the

OR. Using preoperative active warming in addition

to intraoperative active warming has been found to

be more effective at maintaining normothermia than

use of active warming intraoperatively alone.57-59

In addition to using active warming preopera-

tively, patients should be warmed intraoperativelywith active warming when the surgery is scheduled

for one hour or longer. This intervention should be

initiated before induction of anesthesia. The tech-

nology should be used in a manner consistent with

the manufacturers IFU. Using a FAW machine and

hose without a FAW blanket concentrates heat in

one location and has resulted in serious patient

burns.60 This hosing should never be tolerated.

Warmed IV fluids should be used in addition to

FAW to minimize heat loss when more than 1 L of

fluid or refrigerated fluid is administered. Admin-

istering cool IV fluids increases heat loss; admin-

istering 1 L of room temperature solution decreases

the mean body temperature by 0.25 C (0.45 F).61

Patients often receive more than 1 L of IV fluid

during surgery, compounding this decrease. Pre-

warming IV fluids in a warming cabinet or using

an inline fluid warmer mitigates heat loss. Surgical

patients who receive warmed IV fluids have been

found to have 0.4 C to 0.9 C (0.72 F to 1.62 F)

higher core temperatures than those receiving room

temperature fluids.61-65 The amount of heat trans-

ferred by using prewarmed IV solutions is inade-

quate alone to prevent hypothermia, however. In

one study, 32% of subjects receiving room tem-

perature IV fluids were hypothermic on arrival in

the postanesthesia care unit, compared with 14% of

those receiving warmed IV fluids.62 In addition

to evaluating compliance with the SCIP quality

performance measure for external reporting, we

recommend that perioperative quality management

programs include evaluating compliance with three

evidence-based practicesdpreoperative FAW, in-

traoperative FAW, warmed IV fluidsd

and patientoutcomes to determine the effectiveness of inter-

ventions used.

9. PREVENTING BURNS FROM ENERGY

DEVICES

More than 25% of nurses surveyed identified pre-

vention of burns from energy devices to be a pri-

ority issue.6 In ASCs, this issue was more likely to

be an identified priority than in hospitals (31.9%

versus 25.3%). The reason for this difference maybe the use of a variety of energy devices in a con-

centrated amount of time during procedures in

ASCs compared with hospitals.

Burns are estimated to occur in 11.9 per 100,000

admissions.66 Two-thirds of these burns are thermal

in nature, and more than half are from instruments

or devices used during procedures (eg, electrosur-

gery, electrocautery, light sources). More than half

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of electrosurgery burns result from direct coupling

when the electrosurgery unit is inadvertently acti-

vated.67 Some of these burns resulted from not

placing the active electrode in the holster when it

was not in use. Capacitive coupling has resulted

from insulation failure and the electrode touching

a metal instrument.68 Another energy device that

may lead to patient injury is the phacoemulsifier

used in cataract surgery. More than 1,400 corneal

burns during phacoemulsification have been re-

ported.69 Insufficient irrigation fluid can lead to

overheating of the probe and burns to surrounding

tissue. Contributing factors to burns from phacoe-

mulsifiers include a lack of familiarity with the

irrigation and aspiration equipment, the surgeons

lack of experience with the equipment, and human

error.69 Anecdotal reports from nurses also indicate

that the dimmed lights in the OR during ophthalmic

surgery in particular make it difficult to view the

aspirating fluid level.


Regardless of the energy device being used, it is

essential that perioperative personnel be educated

on how to use the device safely, that competency

has been demonstrated, and that the device is usedin a manner consistent with the manufacturers IFU.

When using electrosurgery, personnel should be

aware of the location of the electrode, should not

allow the electrode to touch metal, and should

contain the electrode (eg, in a holster) when it is

not in use. Electrodes should be inspected for in-

sulation failures during reprocessing and after each

use. Dispersive electrodes should be of appropriate

size for the patient. All-metal or all-plastic cannulas

should be used to decrease the risk of capacitivecoupling.68

During phacoemulsification, an irrigation fluid

chamber monitor with an alarm that alerts per-

sonnel to low fluid levels should be used. An extra

bottle of fluid should be readily accessible in the

OR for immediate use. Supplemental lighting

should be available in the OR and should be used

to assist with visual inspection of fluid levels and

operating equipment. The facilitys perioperative

quality management program should include poli-

cies for documenting education and competency

for each energy device used.

10. RESPONDING TO DIFFICULT

INTUBATION OR AIRWAY EMERGENCIES

The 10th priority perioperative patient safety issue

that surveyed nurses identified was responding to

difficult intubation or airway emergencies.6 Over-

all, 23% of nurses identified this patient safety issue

as a high priority for additional action. A higher

percentage of nurses working in ASCs identified

this issue than those working in hospitals (29.6%

versus 22.1%), and nurses working in smaller

hospitals were more likely to identify this issue

than those working in larger hospitals (25.0% to

26.9% versus 16.0% to 21.3%). This is likely be-

cause larger hospitals have more resources with

which to respond to airway emergencies than ASCs

and small hospitals.

The PPSA first identified management of difficult

airways as a safety issue in 2009, after reviewing 36

reports of anesthesia-related complications associ-

ated with difficult intubations.70 Of these reports,

nearly two-thirds were unanticipated difficult intu-bations. Problems with endotracheal intubation can

result in hypoxia and brain damage and are the most

common cause of anesthesia-related deaths.71

Anecdotal reports from perioperative nurses

indicate that factors that deter an effective team

response to an unanticipated difficult airway in-

clude equipment being located in more than one

place, personnel being unfamiliar with equipment,

having no predetermined plan of action or defined

roles, and having difficulty obtaining expert assis-tance. There also is the potential for making the

assumption that patients in ASCs are healthy pa-

tients who are low risk and personnel are mentally

unprepared to respond.


Perioperative nurses should collaborate with anes-

thesia professionals, otolaryngologists, and nurses

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in other areas in which anesthesia is administered

to develop a comprehensive and institution-wide

difficult airway management program. This pro-

gram should include

n a list of equipment to be stocked,

n a preanesthesia risk assessment,

n discussion of the airway management plan

during preoperative briefings,

n designation of a rapid response team, and

n regularly scheduled multidisciplinary education

and simulation drills.

The American Society of Anesthesiologists Prac-

tice guidelines for management of the difficult

airway, which includes the difficult airway algo-

rithm,72

should be used as a starting point fordiscussions.

Emergency airway management equipment

should be located in one place in every depart-

ment in which anesthesia is administered. The

equipment placed in the difficult airway cart or tool

case should include, at a minimum, a flexible fiber-

optic bronchoscope, a light source, laryngeal mask

airways, airway exchange catheters, and a crico-

thyroidotomy kit. Anesthesia professionals should

be the primary decision makers for what equipmentand supplies are purchased and stocked in this

cart or tool case. The University of California,

San Diego, has a virtual difficult airway manage-

ment cart that can be used as a resource.73 Anes-

thesia assistants should be trained in the care and

cleaning of this equipment, and the cart should be

checked with the same regularity as a code cart to

verify availability of all the equipment and supplies

necessary to respond to an airway emergency. Re-

placement equipment should be in place whenequipment is undergoing routine maintenance or

is being repaired.

There are a number of different tools to assess for

risk of a difficult intubation,74-80 and no one tool is

fail-safe.72 The team should review the evidence

supporting available risk assessment tools and select

one or more appropriate tools for the health care

facility. Surgical team briefings should include

airway risks identified and the plan for management

of any airway issue. There should be a standardized

plan in place to designate a rapid response team. The

contact mechanism should be the same, no matter

who is the responder (eg, same paging mechanism).

After a difficult airway management event, infor-

mation about the event should be communicated

with the patient, primary care provider, and other

health care providers. A Difficult Airway Alert

Form81 can be used or modified to assist with this

communication (Figure 2).

Lastly, the interdisciplinary perioperative team

should regularly practice responding to and man-

aging airway emergencies, as well as assessing

team member competency. It is critical that this

education and training be team-based. Seconds

matter in an airway emergency, and simulation

facilitates the ability of team members to rapidly

respond to emergencies when they arise. A pro-

spective controlled study using simulation showed

that adherence to a difficult airway guideline by

anesthesiologists was sustained for six to eight

months for the cant intubate, cant ventilate

scenario but only six to eight weeks for the more

complex cant intubate scenario. This training

should occur at least every six months.82

SUMMARY

We have reviewed the top 10 patient safety issues

identified through a survey of perioperative nurses,

described the evidence supporting the overall seri-

ousness of these issues, and identified contribut-

ing factors. Based on this evidence, we have made

recommendations for additional steps that periop-

erative nurses can take to enhance patient safety.

Three of these issues have been described as neverevents: wrong site/procedure/patient surgery, re-

tained surgical items, and pressure ulcers. Not only

do these events increase morbidity and mortality,

but the cost of patient care related to these events

is no longer reimbursed by the Centers for Medi-

care & Medicaid Services.83 We highlighted the

factors contributing to these events and made rec-

ommendations that go beyond those traditionally

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Figure 2. The Pennsylvania Patient Safety Authority Difficult Airway Alert Form is a communication tool used to

alert patient care providers that a patient has a potentially difficult airway. It can be modified for the individual

practice setting. Reprinted with permission from the Pennsylvania Patient Safety Authority.

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available to perioperative nurses. Some of these

focus on the value of briefing before and debriefing

after surgery. Others emphasize the value of pro-

spective risk assessment. Regardless of the issue,

perioperative nurses should collaborate with other

disciplines to review national data to identify safety

issues. We should also analyze internal data about

adverse events and near misses and design and im-

plement a corrective action plan based on lessons

learned. Our quest for improving the quality and

safety of perioperative patient care is unending, and

it is a professional responsibility that provides us

with the direction needed to continuously improve

our health care system.

SUPPLEMENTARY DATA

The supplementary figure associated with this

article can be found in the online version at http://

dx.doi.org/10.1016/j.aorn.2013.04.012.

Acknowledgments: The authors thank Deborah

Spratt, MPA, BSN, RN, CNOR, NEA-BC, CRCST,

CHL, manager of the sterile processing department

at Canandaigua Veterans Affairs Medical Center,

Canandaigua, New York, for reviewing the content

on failures in reprocessing instruments and KokilaThenuwara, MBBS, MD, MME, assistant professor,

Department of Anesthesia, College of Medicine,

The University of Iowa, University Heights, for

reviewing the content on responding to difficult

intubation or airway emergencies.

Editors note: The Universal Protocol for Pre-

venting Wrong Site, Wrong Procedure, Wrong

Person Surgery is a trademark of The Joint

Commission, Oakbrook Terrace, IL.

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