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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
AORN Journal j 691
TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
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
TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org
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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airway with known assessment scales. Cir Cir. 2010;
78(5):393-399.
80. Ramachandran SK, Mathis MR, Tremper KK,
Shanks AM, Kheterpal S. Predictors and clinical
outcomes from Failed Laryngeal Mask Airway
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Unique
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: a study of 15,795 patients. Anesthesiology.
2012;116(6):1217-1226.
81. Difcult Airway Alert Form. Pennsylvania Patient Safety
Authority. http://patientsafetyauthority.org/Educational
Tools/PatientSafetyTools/intubation/Documents/alert
.pdf. Accessed April 3, 2013.
82. Kuduvalli PM, Jervis A, Tighe SQ, Robin NM. Unan-
ticipated difcult airway management in anaesthetised
patients: a prospective study of the effect of mannequin
training on management strategies and skill retention.
Anaesthesia. 2008;63(4):364-369.
83. CMS improves patient safety for Medicare and Medicaid
by addressing never events. Centers for Medicare &
Medicaid Services. August 4, 2008. http://www.cms
.gov/apps/media/press/factsheet.asp?Counter3224&int
NumPerPage10&checkDate&checkKey&srchType
1&numDays0&srchOpt0&srchData&keyword
TypeAll&chkNewsType6&intPage&showAll1
&pYear1&year2008&descfalse&cboOrderdate.
Accessed April 17, 2013.
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