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
3.9
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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 identied in an
AORN member survey.
2. Identify methods to mitigate the risks of injury posed by
the identied patient safety issues.
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Conict of Interest Disclosures
As a consultant of RF Surgical Inc, Dr Steelman has declared
an afliation that could be perceived as posing a potential
conict of interest in the publication of this article. Dr Graling
has no declared afliation that could be perceived as posing
a potential conict 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 have
no declared afliations that could be perceived as posing
potential conicts of interest in the publication of this article.
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http://dx.doi.org/10.1016/j.aorn.2013.04.012
AORN, Inc, 2013 June 2013 Vol 97 No 6 AORN Journal j 679
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 identied 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 identied, 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 J 97 (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.
D
uring 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 patients
5
; 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 identied, 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 identied
by 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 ve 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 rst
recommended marking the surgical site and using
a verication checklist.
7
Wrong site/procedure/
patient surgery is estimated to occur 40 times per
http://dx.doi.org/10.1016/j.aorn.2013.04.012
680 j AORN Journal June 2013 Vol 97 No 6 AORN, Inc, 2013
week
8
and remains the second most commonly re-
ported sentinel event to The Joint Commission.
9
The Joint Commission has identied risk points
in processes where wrong-site surgery can be pre-
vented, including scheduling errors, verication
errors, distractions/rushing, inconsistent site mark-
ing, no safety culture, and time-out errors.
8
Re-
searchers observing procedures in eight facilities
in Minnesota identied 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 ofces to implement a
checklist for scheduling surgery. The Pennsylvania
Patient Safety Authority (PPSA) has a checklist for
ofce schedulers
11
and OR schedulers
12
that can be
modied 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 verication. 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 conrmed before each procedure.
The entire time-out process should be repeated
when there is a change of surgeon.
8
The PPSA has identied best practices for reli-
able performance of the Universal Protocol
TM
based
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 Universal
Protocol. 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 Identied by
Perioperative RNs (N [ 3,137)
1
Safety issue %
1. Preventing wrong site/procedure/patient surgery 69
2. 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 res 35
8. Preventing perioperative hypothermia 31
9. Preventing burns from energy devices 26
10. Responding to difcult intubation or airway
emergencies
23
1. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety
issues identied by perioperative nurses. AORNJ. 2013;97(4):402-418.
AORN Journal j 681
TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
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 SURGICAL
ITEMS
Sixty-one percent of the nurses who were surveyed
identied 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
identied 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 identied 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 eld, 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 an
OR and are difcult to control.
AORNs Recommended practices for preven-
tion of retained surgical items was signicantly
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 Sponges
1
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 fast
n 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.
682 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
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 reect 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) identied preventing medication errors to
be a high priority.
6
The higher percentage in ASCs
likely reects 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-inammatory agents
(3.8%). The most common medications associ-
ated with errors identied 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, specic contributing factors include
communication failures or overlooking preopera-
tive orders, choosing the wrong ophthalmic medi-
cation, failing to label medications on the sterile
eld, and relying on color coding rather than
medication labels.
19
What More Can We Do?
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 who
work 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 eld. This service minimizes
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TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
distractions and contamination when medications
are being mixed and dispensed onto the sterile eld.
We need to make a concerted effort to minimize
verbal orders by implementing standard order sets
and implementing briengs 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 identied
preventing failures in instrument reprocessing to
be a high priority for action; 48% of nurses working
in ASCs and 59% of nurses in federal hospitals
rated this issue a high priority.
6
These differences
likely reect 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 in
reprocessing 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.
What More Can We Do?
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 expected
standards. 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,
684 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
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 into
the 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 difcult to achieve.
AORN recommends that immediate use steam
sterilization (IUSS) only be used when there is
insufcient 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 adequate
instrument 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 eld, 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 certied 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 exible 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 programshould 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 Advancement
of 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 events
23-25
have raised the level
of concern and instilled a sense of urgency for
action 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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TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
5. PREVENTING PRESSURE INJURIES
Overall, 40% of the nurses surveyed identied
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 increased
risk. Impaired circulation from peripheral vascular
disease and hypotension during surgery also de-
crease perfusion. Furthermore, devices used intra-
operatively to prevent blood ow to the surgical site
(eg, tourniquet, vascular clamps) prevent blood ow
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 orthopedic
33
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 nurses
should 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 of
Medical Instrumentation (AAMI); 2011. http://www.aami.org/meetings/summits/reprocessing/Materials/2011_Reprocessing_Summit_publication.pdf.
Accessed April 8, 2013.
686 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
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 exed 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 claried 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, perioperative
nurses 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-ve percent of the nurses responding to our
survey identied 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 reect 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 identication 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 condence 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.
What More Can We Do?
Preventing specimen management errors requires
ensuring communication in the OR, labeling of
specimens accurately, eliminating multitasking
during specimen management, and ensuring veri-
cation before sending the specimen out of the
OR. Communication about specimens should be
included in a preoperative brieng with the sur-
geon. AORNs Comprehensive Surgical Checklist,
based on recommendations from The Joint Com-
mission and the World Health Organization, in-
cludes a brieng and debrieng model that can
be modied 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-
ers.
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 unused
labels are removed from the room at the end of
the procedure. Multitasking during specimen man-
agement should be avoided. Lastly, a debrieng
with the surgeon at the end of the procedure
should include reviewing the identication of
specimens that were obtained and of the xative
that was used. Before transferring the specimen
out of the OR, two people should verify the label
AORN Journal j 687
TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
Figure 1. The AORN Comprehensive Surgical Checklist, which includes a brieng, time out, and debrieng to enhance patient safety, can be modied for
the individual practice setting. Copyright 2012, AORN, Inc. All rights reserved. Reprinted with permission.
6
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and contents, similar to the verication 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 res 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 res 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 prep
agents containing alcohol has increased dramati-
cally. Use of these agents, accompanied by time
pressure, increases the risk of surgical res. Often,
there is inadequate communication among members
of the surgical team about the risk of re, so the
person using the ignition source may be unaware
of an open oxygen source or alcohol fumes.
What More Can We Do?
The US Food and Drug Administration has devel-
oped comprehensive recommendations for prevent-
ing surgical res.
43
We recommend implementing
these recommendations as part of a re safety
program:
n provide multidisciplinary training and drills,
n perform a re risk assessment before making
the initial incision,
n communicate about the use of an open source of
oxygen or ammable prep agent before making
the incision,
n allow ample time for ammable prep agents to
dry, and
n holster the electrosurgery pencil when it is not
in use.
Conducting a re risk assessment is extremely
important and should include aspects uniquely re-
lated to the specic procedure (Table 4). Fire
safety should be openly discussed during the
brieng 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 res, this
program also should include ongoing monitoring
of compliance. The Fire Safety Tool Kit,
44
avail-
able as a free member benet from the AORN
web site, contains tools to assist in proactively
promoting re prevention, planning effective re-
sponse strategies, and developing department-
specic 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 rst
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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TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
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 Brieng: 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 Congure surgical drapes to allow sufcient 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 ber-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 ammable chemicals (eg, alcohol, collodion) on the sterile eld 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 ammability.
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/resafety. Accessed April 8, 2013.
690 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
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.
What More Can We Do?
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 uids, 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 hypothermia
56
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 intraoperatively
with 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 uids should be used in addition to
FAW to minimize heat loss when more than 1 L of
uid or refrigerated uid is administered. Admin-
istering cool IV uids 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 uid
during surgery, compounding this decrease. Pre-
warming IV uids in a warming cabinet or using
an inline uid warmer mitigates heat loss. Surgical
patients who receive warmed IV uids 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 uids.
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 uids were hypothermic on arrival in
the postanesthesia care unit, compared with 14% of
those receiving warmed IV uids.
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 uidsdand patient
outcomes to determine the effectiveness of inter-
ventions used.
9. PREVENTING BURNS FROM ENERGY
DEVICES
More than 25% of nurses surveyed identied pre-
vention of burns from energy devices to be a pri-
ority issue.
6
In ASCs, this issue was more likely to
be an identied priority than in hospitals (31.9%
versus 25.3%). The reason for this difference may
be 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 phacoemulsier
used in cataract surgery. More than 1,400 corneal
burns during phacoemulsication have been re-
ported.
69
Insufcient irrigation uid can lead to
overheating of the probe and burns to surrounding
tissue. Contributing factors to burns from phacoe-
mulsiers 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 difcult to view the
aspirating uid level.
What More Can We Do?
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 used
in 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 capacitive
coupling.
68
During phacoemulsication, an irrigation uid
chamber monitor with an alarm that alerts per-
sonnel to low uid levels should be used. An extra
bottle of uid 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 uid 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 identied was responding to
difcult intubation or airway emergencies.
6
Over-
all, 23% of nurses identied this patient safety issue
as a high priority for additional action. A higher
percentage of nurses working in ASCs identied
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 rst identied management of difcult
airways as a safety issue in 2009, after reviewing 36
reports of anesthesia-related complications associ-
ated with difcult intubations.
70
Of these reports,
nearly two-thirds were unanticipated difcult 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 difcult airway in-
clude equipment being located in more than one
place, personnel being unfamiliar with equipment,
having no predetermined plan of action or dened
roles, and having difculty 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.
What More Can We Do?
Perioperative nurses should collaborate with anes-
thesia professionals, otolaryngologists, and nurses
692 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
in other areas in which anesthesia is administered
to develop a comprehensive and institution-wide
difcult 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 briengs,
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 difcult
airway, which includes the difcult airway algo-
rithm,
72
should be used as a starting point for
discussions.
Emergency airway management equipment
should be located in one place in every depart-
ment in which anesthesia is administered. The
equipment placed in the difcult airway cart or tool
case should include, at a minimum, a exible ber-
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 equipment
and supplies are purchased and stocked in this
cart or tool case. The University of California,
San Diego, has a virtual difcult 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 when
equipment is undergoing routine maintenance or
is being repaired.
There are a number of different tools to assess for
risk of a difcult 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 briengs should include
airway risks identied 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 difcult airway management event, infor-
mation about the event should be communicated
with the patient, primary care provider, and other
health care providers. A Difcult Airway Alert
Form
81
can be used or modied 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 difcult 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
identied through a survey of perioperative nurses,
described the evidence supporting the overall seri-
ousness of these issues, and identied 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 never
events: 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
AORN Journal j 693
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Figure 2. The Pennsylvania Patient Safety Authority Difcult Airway Alert Form is a communication tool used to
alert patient care providers that a patient has a potentially difcult airway. It can be modied for the individual
practice setting. Reprinted with permission from the Pennsylvania Patient Safety Authority.
694 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
available to perioperative nurses. Some of these
focus on the value of brieng before and debrieng
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 gure 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 Kokila
Thenuwara, MBBS, MD, MME, assistant professor,
Department of Anesthesia, College of Medicine,
The University of Iowa, University Heights, for
reviewing the content on responding to difcult
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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Victoria M. Steelman, PhD, RN, CNOR,
FAAN, is an assistant professor at The Univer-
sity of Iowa College of Nursing, Iowa City,
Iowa. As a consultant of RF Surgical, Inc, Dr
Steelman has declared an afliation that could
be perceived as posing a potential conict of
interest in the publication of this article.
Paula R. Graling, DNP, RN, CNOR, is the
clinical nurse specialist of Perioperative Services
at Inova Fairfax Hospital, Falls Church, VA.
Dr Graling has no declared afliation that could
be perceived as posing a potential conict of
interest in the publication of this article.
698 j AORN Journal
June 2013 Vol 97 No 6 STEELMANdGRALING
EXAMINATION
CONTINUING EDUCATION PROGRAM
3.9
www.aorn.org/CE
Top 10 Patient Safety Issues:
What More Can We Do?
PURPOSE/GOAL
To enable the learner to proactively intervene to mitigate risks for the top peri-
operative patient safety issues.
OBJECTIVES
1. Describe the top patient safety issues identied in an AORN member survey.
2. Identify methods to mitigate the risks of injury posed by the identied patient
safety issues.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. The number one patient safety issue identied in
a survey of perioperative nurses is preventing
a. perioperative hypothermia.
b. wrong site/procedure/patient surgery.
c. retained surgical items.
d. medication errors.
2. Recommendations for preventing retained
surgical items include
1. minimizing distractions and multitasking
while managing counted items.
2. alerting the team that the count will be
starting.
3. prioritizing other urgent tasks before starting
the count.
4. actively enforcing the facilitys procedures
for managing counted items.
5. evaluating adjunct technology to support the
surgical count.
6. taking intraoperative radiographs for all
abdominal procedures.
a. 1, 2, and 3 b. 4, 5, and 6
c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
3. Opportunities to prevent medication errors
include
1. minimizing verbal orders.
2. implementing standard order sets.
3. implementing briengs with the surgeon
before each procedure.
4. using surgeon preference cards to identify
doses.
5. labeling medications and solutions that are
removed from their original containers.
6. communicating with the surgeon when
handing off medications.
a. 1, 3, and 5 b. 2, 4, and 6
c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
AORN, Inc, 2013 June 2013 Vol 97 No 6 AORN Journal j 699
4. Reprocessing instruments in the OR is high risk
because
a. the decontamination equipment in the OR is
not adequate to properly reprocess instruments.
b. OR personnel may try to circumvent the rigor
required for effective reprocessing.
c. OR personnel are not trained to properly
reprocess instruments.
d. sterilizers in the OR have a higher failure rate.
5. To safely transfer and position patients in
a manner that prevents shearing, personnel should
use a mechanical lifting device for a supine-to-
supine transfer of a patient weighing more than
a. 157 lb. b. 175 lb.
c. 187 lb. d. 195 lb.
6. To prevent errors with specimen management,
perioperative personnel should
1. avoid multitasking during specimen
management.
2. ensure that two people verify the label and
contents before transferring the specimen out
of the OR.
3. discuss anticipated specimens in the preop-
erative brieng with the surgeon.
4. label specimens with two unique identiers.
5. perform a debrieng with the surgeon at the
end of the procedure to review specimen
identication and the xative used.
6. verify the accuracy of information on each
patient label.
a. 1, 3, and 5 b. 2, 4, and 6
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
7. Recommendations that could be part of a re
safety program include
1. allowing ample time for ammable prep
agents to dry.
2. communicating about the use of an open
source of oxygen or ammable prep agent
before making the incision.
3. holstering the electrosurgery pencil when it is
not in use.
4. performing a re risk assessment before
making the initial incision.
5. providing multidisciplinary training and
drills.
a. 4 and 5 b. 1, 2, and 3
c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
8. Perioperative hypothermia is an important issue
for all anesthetized surgical patients because it
1. increases the risk of postoperative surgical
site infection.
2. causes coagulopathy and the need for
transfusion.
3. extends the duration of neuromuscular
blocking agents and delays recovery.
4. triples the risk of a morbid cardiac event
occurring.
5. increases the risk of renal failure and need for
dialysis.
a. 4 and 5 b. 1, 2, and 3
c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
9. Important safety measures to implement during
phacoemulsication include
1. ensuring that an appropriately sized disper-
sive electrode is placed on all patients.
2. ensuring that an extra bottle of uid is readily
accessible in the OR for immediate use.
3. providing supplemental lighting in the OR to
assist with visual inspection of uid levels
and operating equipment.
4. using an irrigation uid chamber monitor
with an alarm that alerts personnel to low
uid levels.
a. 1 and 3 b. 2 and 4
c. 2, 3, and 4 d. 1, 2, 3, and 4
10. ________________ should be the primary
decision makers for what equipment and supplies
are purchased and stocked in the difcult airway
management cart.
a. Anesthesia professionals
b. OR nurses
c. Postanesthesia care unit nurses
d. Surgeons
700 j AORN Journal
June 2013 Vol 97 No 6 CE EXAMINATION
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
3.9
www.aorn.org/CE
Top 10 Patient Safety Issues:
What More Can We Do?
T
his evaluation is used to determine the extent
to which this continuing education program
met your learning needs. Rate the items as
described below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the top patient safety issues identied in an
AORN member survey.
Low 1. 2. 3. 4. 5. High
2. Identify methods to mitigate the risks of injury posed
by the identied patient safety issues.
Low 1. 2. 3. 4. 5. High
CONTENT
3. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
4. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High
5. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
6. Will you change your practice as a result of reading
this article? (If yes, answer question #6A. If no,
answer question #6B.)
6A. How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: _______________________________
6B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: ________________________________
7. Our accrediting body requires that we verify
the time you needed to complete the 3.9 con-
tinuing education contact hour (234-minute)
program: _________________________________
AORN, Inc, 2013 June 2013 Vol 97 No 6 AORN Journal j 701