Common Breaks in Sterile

Technique: Clinical Perspectives

and Perioperative Implications
WILLIAM R. HOPPER, MD, FAAOS; ROSE MOSS, RN, MN, CNOR
3.4
ABSTRACT
Prevention of health care-associated infections, specically surgical site infections,
is a fundamental responsibility of the perioperative team. Breaks in sterile technique
can and do occur, even for the most conscientious perioperative practitioners.
Surgical site infections are associated with unnecessary patient pain and suffering
and increased lengths of hospital stay and health care costs. Prevention of surgical
site infections, therefore, takes on great signicance in todays dynamic health care
environment. Key responsibilities of perioperative nurses are to recognize and
correct common breaks in sterile technique that are made in preparation for and
during a surgical procedure and to implement methods to prevent future occurrences.
AORN J 91 (March 2010) 350-364. AORN, Inc, 2010
Key words: sterile technique, aseptic technique, asepsis, surgical site infections,
health care-associated infections.
P
reventing infections in the surgical patient
is a primary responsibility of every mem-
ber of the perioperative team. One of the
expected outcomes for surgical intervention is that
the patient is free from signs and symptoms of
infection.
1
Health care-associated infection (ie, an
infection that a patient acquires during the course
of receiving treatment for other conditions in a
health care setting) is one of the top 10 leading
causes of death in the United States today.
2
In
a recent update, the Centers for Disease Con-
trol and Prevention estimated that health care-
associated infections account for approximately
1.7 million infections and 99,000 associated
deaths each year in US hospitals alone; of these
infections, 22% are surgical site infections (SSIs).
3
The economic burden of SSIs is signicant.
de Lissovoy et al,
4
using data from the 2005
Healthcare Cost and Utilization Project National
Inpatient Sample, identied SSIs in hospital dis-
charge records for seven categories of surgical
procedures performed:
neurological;
cardiovascular;
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350 AORN Journal March 2010 Vol 91 No 3 AORN, Inc, 2010
colorectal;
skin, subcutaneous tissue, and breast;
gastrointestinal;
orthopedic; and
obstetric and gynecologic.
The primary study outcomes were the rate of SSI
by surgical procedure category and the effect of
SSI on hospital length of stay and cost. The re-
searchers identied 6,891 cases of SSI among the
723,490 surgical hospitalizations in the sample
(ie, 1%). On average, an SSI increased length of
stay by 9.7 days and increased costs by $20,842
per admission. The researchers then projected
these results to the national level. National esti-
mates of SSI would result in an additional
406,730 hospital days and hospital costs would
exceed $900 million. An additional 91,613 patient
readmissions for treating the SSIs would account
for an estimated 521,933 extra days of care at a
cost of approximately $674.4 million.
4
For health care facilities, the escalating costs of
treating SSIs were further affected in July 2008
when the Centers for Medicare & Medicaid Ser-
vices announced new payment and coverage poli-
cies.
5
A nal acute care inpatient prospective pay-
ment system rule that updated Medicare payments
to hospitals for scal year 2009 provided addi-
tional incentives for hospitals to improve the
quality of care provided to patients with Medicare
by including payment provisions to reduce pre-
ventable medical errors that occur in hospitals. If
a condition is not present on admission but is
subsequently acquired during the hospital stay,
Medicare will no longer pay the additional cost of
the hospitalization; furthermore, the patient is not
responsible for the additional cost. Initially, hospi-
tals were not reimbursed for infections associated
with vascular catheters and coronary artery bypass
graft surgery. As of October 1, 2008, hospitals
are no longer reimbursed for SSIs after select
elective procedures, including certain orthopedic
surgeries and bariatric surgeries.
5
The 2009 Joint
Commission National Patient Safety Goals also
include requirements for reducing the risk of
health care-associated infections, specically SSIs,
and state that best practices for preventing SSIs
should be implemented.
6
The sources of surgical site microbial contami-
nation may be either resident ora (ie, endoge-
nous microorganisms) or transient ora (ie, exog-
enous microorganisms). Resident ora are
bacteria or microorganisms considered to be per-
manent residents of the skin and are not readily
removed by hand washing.
7
Transient ora are
bacteria or microorganisms that colonize the su-
percial layers of the skin and are more easily
removed by hand washing or use of a hand rub
agent.
7
Transient ora are easily transmitted to
hands from patients and inanimate surfaces. Mi-
crobial contamination of the surgical site can
cause an SSI. The risk of an SSI increases with
the dose of bacterial contamination and the viru-
lence of the bacteria.
8
One potential cause of exogenous microbial
contamination in the OR is a break in sterile tech-
nique. A key responsibility of perioperative
nurses is to recognize and correct common breaks
in sterile technique that are made in preparation
for and during a surgical procedure and to imple-
ment methods to prevent future occurrences.
CATEGORIES OF BREAKS IN STERILE
TECHNIQUE
Breaks in sterile technique can be divided into
four types:
Type 1the break is recognized immediately.
Type 2the break is recognized shortly after
it occurs.
Type 3the break is recognized later.
Type 4the break is not recognized at all.
Although quantifying type 4 breaks is not possi-
ble because they go unrecognized, it is intuitive
to believe that some unrecognized breaks in ster-
ile technique must occur.
The list of recognized breaks is long; theoreti-
cally, it is possible to break sterile technique in
an innite number of ways. Certain breaks in
COMMON BREAKS IN STERILE TECHNIQUE www.aornjournal.org
AORN Journal 351
sterile technique, however, occur repeatedly, such
as stabbing oneself with a needle and thus poten-
tially exposing oneself to bloodborne pathogens,
having the suction or electrosurgical unit (ESU)
active electrode fall over the side of the OR bed,
or brushing ones gown against an unsterile sur-
face. Consider a classic examplethe hole in the
glove. If recognized immediately (ie, a type 1
break), containment (ie, solving the disruption of
the sterile eld and returning it to its former, un-
contaminated state) is possible. If a needle was
the culprit, the scrub person would pass the nee-
dle off the sterile eld in its needle holder, the
circulating nurse would remove the scrubbed per-
sons glove, and the scrubbed person would don
another glove.
With the passage of time, the problem becomes
more complex (ie, a type 2 break). Suppose that
the individual has set the contaminated needle on
a Mayo stand containing other instruments. For
absolute containment to be achieved with a type 2
break, the entire Mayo stand must be taken down
and all of the instruments
resterilized or new ones ob-
tained, which may or may
not be practical or possible.
Invariably, the team pauses
to determine what else has
been contaminated. In these
situations, the team does its
best to cope with the con-
tamination, but containment
may not be possible (eg,
during emergent surgery, for
an unstable patient).
In a type 3 break, a
scrubbed team member looks
down and sees a hole in his
or her glove. The individual
does not know where or
when the hole occurred and
cannot say whether anything
else has been contaminated.
Potentially everything, in-
cluding the incision, could
have been contaminated.
This is an example of a
break in sterile technique
that cannot be contained be-
cause this would require
starting over completely:
irrigating the incision with
antibiotic solution, reprep-
ping, redraping, and begin-
ning again with all new
Most Common Pathogens in HAIs
According to an annual summary from the National Healthcare
Safety Network on the frequency of selected antimicrobial resis-
tance patterns among pathogens causing device-associated and
procedure-associated health care-associated infections (HAIs), the
10 most common pathogens accounting for 84% of HAIs were
coagulase-negative staphylococci (15%),
Staphylococcus aureus (15%),
Enterococcus species (12%),
Candida species (11%),
Escherichia coli (10%),
Pseudomonas aeruginosa (8%),
Klebsiella pneumoniae (6%),
Enterobacter species (5%),
Acinetobacter baumannii (3%), and
Klebsiella oxytoca (2%).
1
As many as 16% of all HAIs were associated with the following
multidrug-resistant pathogens:
methicillin-resistant S aureus (8%),
vancomycin-resistant Enterococcus faecium (4%),
carbapenem-resistant P aeruginosa (2%),
extended-spectrum cephalosporin-resistant K pneumoniae (1%),
extended-spectrum cephalosporin-resistant E coli (0.5%), and
carbapenem-resistant A baumannii, K pneumoniae, K oxytoca,
and E coli (0.5%).
1
1. Hidron AI, Edwards JR, Patel J, et al; National Healthcare Safety Network Team.
NHSN update: antimicrobial-resistant pathogens associated with healthcare-associated infec-
tions: annual summary of data reported to the National Healthcare Safety Network at the
Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol.
2008;29(11):996-1011.
March 2010 Vol 91 No 3 HOPPERMOSS
352 AORN Journal
instruments. Typically, this approach is not prac-
tical because the surgical procedure has started
and time is of the essence, not just for cost rea-
sons but for the patients safety as well. The team
has noticed the unintended contamination, but it
would not be in the patients best interest to start
over. A better option for the patient might be to
simply remove and replace any obviously contam-
inated items and supplies (eg, punctured gloves)
and administer prophylactic antibiotics.
COMMON BREAKS IN STERILE
TECHNIQUE
Common breaks in sterile technique include dif-
culties encountered with sterilization, setting up
and opening the sterile eld, scrubbing and drying
hands, gowning, gloving, positioning, prepping,
draping, the OR environment, and surgical tech-
nique. Breaks in sterile technique can and do oc-
cur, even for the best and most conscientious
perioperative practitioners.
Sterilization
Preparation for a surgical procedure actually starts in
the central processing department. Without sterilized
instruments, there can be no sterile technique. Elab-
orate mechanisms, often only vaguely known to
surgeons, are used to ensure quality control in the
central processing department. Steam sterilization
requires specic steam chamber temperatures and
appropriate exposure times, and all parameters must
be monitored regularly. Conrmation of sterilization
parameters when using other methods (eg, low-
temperature hydrogen peroxide gas plasma, ethylene
oxide, ozone) may be more complex compared with
steam sterilization.
There are numerous points in the decontamina-
tion and sterilization process where problems can
occur. Despite advances in technology, disposable
drapes and packaging remain water resistant
rather than waterproof. Wet spots may occur from
condensed steam that has soaked through a sterile
package. These wet spots may wick contamina-
tion into the package. Perioperative personnel
may not check sterility indicator tapes as re-
quired. These tapes turn a distinctive color and
pattern when a dened level of exposure is
reached. Knowledge is critical in the sterilization
process. For instance, sterilization tape cannot be
used again after it has gone through a sterilization
cycle because it will have turned color, thus giv-
ing the impression that the item has been pro-
cessed through a sterilization cycle when in fact it
has not. Small holes or punctures may occur in
the packaging that perioperative personnel may
not notice even when they check the item. To
ensure that items used in the sterile eld are ster-
ile, perioperative personnel preparing an OR for a
procedure must inspect all items immediately be-
fore they are presented to the sterile eld for
proper packaging,
correct processing,
an intact seal,
package container integrity, and
inclusion of the proper sterilization indicator.
9
The item should not be used if any of these prob-
lems are identied during the inspection process.
Setting Up and Opening
Assuming that the instruments are properly steril-
ized, the circulating nurse, scrub person, and
other members of the perioperative team set up
and open the instruments and supplies for the pro-
cedure. This process, although routine, may be
fraught with opportunities for breaking sterile
technique. The steps for preparing a sterile eld
require concentration and should never be hurried.
All items introduced to the sterile eld should be
opened, dispensed, and transferred by methods
that maintain both their sterility and integrity.
9
The circulating nurse and scrub person are well
versed in setting up and preparing a sterile eld;
they do this many times a day. In fact, they do it
so often, it can become routine, and by sheer vol-
ume, some errors may seem inevitable.
Not checking sterility indicators. All steril-
ized packages, regardless of size, should have
sterility indicators on and in them. The color
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AORN Journal 353
change is very easy to recognize. Overlooking
this is very uncommon but can occur. The indica-
tor should be visually inspected immediately to
verify the appropriate color change for the se-
lected sterilization process.
9
Not noticing tears in sterile packaging. Recog-
nizing holes or tears in sterile packaging may not
be as easy as it sounds. Metal trays may tear their
covers at corners, and it is time consuming to
examine them all. Small holes may be missed,
especially when the scrub person and circulating
nurse are hurrying. All items presented to the
sterile eld should be inspected immediately be-
fore presentation.
Not recognizing soaked-through spots.
Most sterile packages are wrapped in water-
resistant packaging material. Waterproof packag-
ing material (ie, plastic) does not tolerate heat
well. It is possible to have questionable wet spots
in the packaging material. If there is any possibil-
ity that moisture is present, the items should be
considered unsterile, should not be used, and
should be returned for reprocessing.
Contaminating the sterile eld, instruments,
or supplies. Perioperative textbooks emphasize
this caveat: unsterile individuals must not touch
or reach over a sterile eld or allow any unsterile
item to contaminate the eld.
10
All items should
be delivered to the sterile eld in a manner that
prevents nonsterile objects or personnel from ex-
tending over the sterile eld.
9
If care is not taken,
it is possible to touch the inside of a package
while opening it. It is also possible for the outside
of the package to touch the inside, sterile portion.
Use of covered metal containers has helped mini-
mize chances for contamination. The instruments
are lifted out of the containers by recessed metal
trays with hinged handles. A good rule when
handing an item directly to a scrubbed person is
to have both the opener (eg, circulating nurse)
and receiver (eg, scrub person) concentrate on the
act together, watching carefully to observe for
inadvertent breaks in technique.
Charnley
11
recommends using as few sets of
instruments as possible to minimize the risk of
contamination when opening a sterile eld and to
avoid clutter, which increases the chance of
breaking sterile technique. Few surgeons have
followed his example.
11
Some larger procedures
require opening of a large number of trays, many
of which are only needed for an instrument or
two. Some facilities have worked to consolidate
sets and supply packaging. Some instruments can
be packaged individually to minimize the number
of sets being opened for one or two instruments,
but this still requires opening numerous individual
instruments. Obtaining consensus among surgeons
regarding what is needed in an instrument set or
procedure pack is not always easy. Having preas-
sembled supply packs saves time in picking the
case and opening for the procedure and minimizes
the opportunity for contamination. If the contents
of the pack are not selected carefully, however,
supplies can be wasted.
Improperly delivering solutions. Delivering
solutions to the sterile eld may not be easy.
When solutions, such as normal saline irrigation,
must be dispensed onto the sterile eld, the scrub
person should place the labeled solution recepta-
cle near the edge of the sterile eld to permit the
circulating nurse to pour the solution without con-
taminating the sterile eld, or the scrub person
should hold the labeled solution receptacle while
the circulating nurse pours the entire contents of
the container slowly to avoid splashing.
9
Any re-
maining uid should be discarded because the
edge of the container is considered contaminated
after the contents have been poured.
Medications should be delivered to the sterile
eld in an aseptic manner. The circulating nurse
should not remove the vial stoppers to pour the
medication into a labeled receptacle on the sterile
eld. For example, bupivacaine hydrochloride can
come in a ip-top bottle. It is easy to contaminate
the medication if the circulating nurse attempts
to ip off the top with a ngertip and pour the
March 2010 Vol 91 No 3 HOPPERMOSS
354 AORN Journal
solution from the other side. This technique risks
the nger touching the edge of the bottle and the
solution becoming contaminated as it is poured
over the edge. Instead, the circulating nurse
should use a sterile transfer device (eg, sterile vial
spike, lter straw, plastic catheter).
9
Improperly moving tables. The risk exists
that unsterile scrub attire can touch sterile drapes
on tables and stands. Tables are sterile only at
table level; only the top surface of a draped table
is considered sterile.
10
The circulating nurse must
always move draped tables by grasping them well
below the sterile drape. The scrub person should
not move tables by grabbing around the top and
underside of the tabletop with gloved hands. If
the scrub person needs to move the table, he or
she should push on the top of the table with
gloved hands.
Leaving sterile supplies open too long. Situ-
ations have occurred in which the instruments
and supplies for a procedure have been opened
and set up but the procedure is delayed, for ex-
ample, because of the need to repeat a test or be-
cause the surgeon is unavoidably delayed. What-
ever the reason, instruments and supplies are left
out. In the past, sterile drapes were used to cover
tables in these situations, but this practice has
been abandoned because of the risk of contami-
nating the sterile items when placing and remov-
ing the sterile drape. In particular, removing the
drape could result in a part of the drape that was
below the table level being drawn above the table
level or air currents drawing microorganisms
from a nonsterile area to the sterile eld.
9
The
current recommendation, therefore, is that sterile
elds should not be covered;
9
this raises the
question, how long is it safe to leave the setup
open? There is no specied amount of time that a
setup can remain open and unused and still be
considered sterile; the sterility of an open eld is
event related, and the eld requires continuous
visual observation.
9
Surgical Hand Antisepsis
The skin can never be rendered sterile, but it can
be made surgically clean by reducing the number
of microorganisms.
10(p79)
Transient and some
resident bacteria can be removed by effective sur-
gical hand antisepsis. Anecdotal evidence sug-
gests that enforcement of hand antisepsis rules
may be lax in some surgical suites. Perioperative
personnel are on an honor system, but perceived
lack of time may adversely affect individual hand
antisepsis practices. The facility should implement
a hand antisepsis policy that includes
removing rings, watches, and bracelets;
keeping ngernails short, clean, and healthy;
not wearing articial nails;
donning a mask before scrubbing;
prewashing the hands and forearms with soap
and running water immediately before per-
forming the surgical hand scrub if hands are
visibly soiled; and
cleaning the subungual areas of both hands
under running water using a disposable nail
cleaner.
7
A three- to ve-minute, standardized, anatomic,
timed method
7
for surgical hand antisepsis using
an antimicrobial scrub solution that has met US
Food and Drug Administration requirements for
surgical hand antisepsis should be used to reduce
microbial bioburden.
7
Alcohol-based solutions
(eg, alcohol-based surgical hand rubs) reduce bac-
terial count on hands more rapidly than do anti-
microbial soaps or detergents. A standardized
protocol for their use should follow the manufac-
turers written instructions.
7
When drying scrubbed hands and forearms, the
top half of the towel is held securely with one
hand and the opposite ngers and hand are thor-
oughly blotted dry before moving to the forearm;
the lower end of the towel is then grasped with
the dried hand and the same procedure is used to
dry the second hand and forearm.
10
The towel
should not touch the scrub suit.
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AORN Journal 355
Gowning
Gowning should occur on a separate table. The front
of a sterile gown is considered sterile from the chest
to the level of the sterile eld.
9
Therefore, only the
inner side of a sterile gown can be touched when
picking it up, usually at the neck. As a result of the
way gowns are folded, a ngertip inadvertently can
graze the front of the gown if the ngertip strays
from the inside of the gown. Another aseptic break
in gowning another person can occur when a scrub
person grazes the surgeons shoulders with the
gloved ngertips as the gown is cinched up.
The white cuffs at the wrists of the gown are
made of soft, permeable material that is not wa-
terproof. The sleeve cuffs
are considered unsterile
when the scrubbed persons
hands pass beyond the cuff
and also because they tend
to collect moisture and are
not an effective bacterial
barrier.
9,10
If the surgical
gloves do not cover the
cuffs, contamination may
occur from inside out or
from outside in. This is es-
pecially dangerous when the
clinicians hands are deep in
the patients body, such as
in the abdominal cavity.
Gloving
There are three methods of
gloving: open, closed, and
assisted.
10
The open method
is fraught with potential for
aseptic breaks, for obvious
reasons. It is difcult not to
touch any part of the skin to
the sterile glove exterior;
therefore, this method should
be performed with care. It is
not acceptable to tolerate
poor open gloving technique;
rather, it is better to start
over. The open method is
used for many minor proce-
dures, from emergency de-
partment suturing to admin-
istering spinal anesthesia,
but it can be used during a
Gowning and Draping Materials
The best materials for gloves, gowns, and drapes remains a con-
troversial subject. Disposable gowns and drapes have proven their
worth because washable, reusable fabric or linens of the past can-
not remain waterproof. Some facilities still use washable linens,
however, and reusable fabrics that are breathable and waterproof
continue to evolve, including polyester microbers and porous
forms of polytetrauoroethylene bonded between two layers of
lightweight polyester. Cost is a signicant factor, especially in
developing countries, but the cost of washing, sterilizing, storing,
and replacing linens must also be considered. Disposables may
replace reusables over time, even in underdeveloped countries,
although dealing with hospital waste has become a pressing issue.
The disposable gowns and drapes of today provide an effective
uid-proof sterile barrier.
1
The shiny, plastic, adhesive-bordered
drapes, laparotomy drapes, and extremity drapes have been em-
braced in the surgical environment. See-through, adhesive plastic
drapes (eg, antiabsorbent adhesive drapes, incise drapes) have be-
come popular in many draping situations, although sometimes they
are not practical (ie, in hand and foot surgery). These drapes may
or may not be impregnated with an antimicrobial agent in the ad-
hesive.
1
When selecting surgical drapes, personnel should consult
practice standards, guidelines, and recommended practices, such as
AORNs Recommended practices for selection and use of surgi-
cal gowns and drapes
2
and the Association for the Advancement
of Medical Instrumentation guideline Liquid Barrier Performance
and Classication of Protective Apparel and Drapes Intended for
Use in Health Care Facilities.
3
1. Mews P. Establish and maintain the sterile eld. In: Phippen M, Ulmer B, Wells M,
eds. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver,
CO: Competency and Credentialing Institute; 2009:272.
2. Recommended practices for selection and use of surgical gowns and drapes. Periop-
erative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:127-131.
3. ANSI/AAMI PB70 Liquid Barrier Performance and Classication of Protective Ap-
parel and Drapes Intended for Use in Health Care Facilities. Arlington, VA: Association
for the Advancement of Medical Instrumentation; 2003.
March 2010 Vol 91 No 3 HOPPERMOSS
356 AORN Journal
surgical procedure when the scrub person discov-
ers a hole in the glove. He or she may change the
glove by having the circulating nurse pull it off
and then proceed to put on a new glove using the
open method. It would be better to be regloved
using the assisted method, but the scrub person
may not wish to or be able to disturb the team.
The closed method is better, but not perfect.
The scrub person uses the cuff of the gown or the
gown itself to perform a modied open technique.
When the scrubbed persons hands protrude
through the sleeve cuffs, the cuffs should be con-
sidered contaminated.
9
The assisted method is the usual way to glove
the surgeon and his or her assistants. Although it
is the safest, it also can be complex. As the scrub
person spreads the glove apart, the surgeons skin
or hair may touch the glove exterior as the hand
enters the glove. The key is for the scrub person
to spread the glove as widely and as circumferen-
tially as possible. Neither the scrub person nor the
surgeon should hesitate to mention if a possible
break in technique is suspected.
Sterile gloves that become contaminated in any
manner should be changed as soon as possible.
9
Scrubbed personnel should inspect gloves for in-
tegrity after donning them.
9
When a hole in a
glove is identied, the surgical team should at-
tempt to isolate all equipment suspected of being
contaminated. Irrigating the incision and applying
additional drapes should be considered.
Double gloving is increasingly popular. Many
surgeons wear two gloves to apply the drapes,
discard the outer pair of gloves after draping the
surgical site but before beginning the procedure,
and then don new outer gloves after draping. Tac-
tile sensation may be diminished, but the trade-off
is that a small hole in the outer glove may not
penetrate through the inner glove. The Centers for
Disease Control and Prevention, the American
College of Surgeons, and the American Academy
of Orthopaedic Surgeons support the practice of
double gloving during invasive procedures.
8,12,13
Another possible break can occur when turning
the gown after gowning and gloving. The scrub
person may turn his or her gown with another
scrubbed person or turn it with a nonscrubbed
person (eg, the circulating nurse). If the scrub
person turns with a nonscrubbed person, the scrub
person hands the tie for turning to the non-
scrubbed person; care must be taken to prevent
the tie from striking the nonscrubbed persons
bare hand as it traverses the cardboard tab. This
break in technique may go unnoticed, especially
if it occurs quickly or if staff members are hurry-
ing. One solution is to insist on turning with a
scrubbed person; however, often this is not possi-
ble for the scrub person because no one else is
scrubbed in at the time.
Positioning the Patient
Some of the positions required for optimal surgi-
cal exposure may make draping the patient awk-
ward. Typically, this is not a problem with ab-
dominal surgery or other procedures performed in
the supine position. Positioning should always be
accomplished with draping in mind; any awk-
wardness in draping increases the chance of a
break in technique. The portion of the sterile sur-
gical drape that establishes the sterile eld should
not be moved after it has been placed; moving the
sterile drape may compromise the sterility of the
eld.
9
Performing the Surgical Skin Prep
Skin cannot be sterilized; it is merely disinfected.
The goal of performing a surgical skin prep is to
reduce the risk of postoperative SSIs by
removing soil and transient microorganisms
from the skin,
decreasing the resident microbial count to sub-
pathogenic levels, and
inhibiting rapid rebound growth of micro-
organisms.
14
In the past, vigorous washing was recommended,
and clinicians believed that the longer the skin
was prepped (eg, 10 minutes), the better. It was
later theorized, however, that long, vigorous
COMMON BREAKS IN STERILE TECHNIQUE www.aornjournal.org
AORN Journal 357
washing could actually increase dangerous ora
by bringing to the surface deeper bacteria lurking
in the dermis or could cause damage to the pa-
tients skin; therefore, rapid, gentle washing might
be best.
The basic tenets of prepping are to
begin at the center (ie, at the point of the inci-
sion) and continue to the periphery of the area
and
never bring a soiled applicator back over a
previously prepped surface.
10
A common error is
to not follow this
principle rigorously.
Another error is for
the circulating nurse
to don the prep
gloves and pick up
the unscrubbed ex-
tremity; when prep-
ping the extremity, the circulating nurse moves
his or her hand from the unscrubbed section (eg,
ankle) to a scrubbed section (eg, lower calf). This
action breaks technique by contaminating the al-
ready scrubbed area. Using positioning devices
and draping them appropriately during the scrub
process can prevent this problem.
Draping
Draping is very important for minimizing the
chance of breaks in sterile technique. The princi-
ple is simple: sterile drapes are used to establish a
sterile eld in which to operate.
9
During surgical
site draping, the potential for complications
abounds. When clinicians are moving in the ster-
ile eld, their gowns can billow, even when the
gowns are turned and tied. All personnel moving
in or around a sterile eld should do so in a man-
ner that maintains the sterile eld without con-
taminating it. Nonscrubbed personnel should
maintain a distance of at least 12 inches from all
parts of and people in the sterile eld.
9
The sterile area of the gown front extends from
the chest to the level of the sterile eld.
9
Without
proper care and attention to detail, it is easy to
contaminate the front of the gown when draping
the sterile eld. For example, when placing a
rolled towel around an extremity, the clinician
leans forward and it is easy to contaminate the
front of the gown on the arm board or OR bed.
This may go unrecognized because the clinician
is concentrating on applying the rolled towel.
Another common error is to touch the prepped
skin or tourniquet when rolling the towel. The
rolled towel concept was classically used to estab-
lish a proximal bor-
der. A stockinette
was then rolled up to
it and the cuff of the
stockinette was used
to secure half-sheets
with nonperforating
clamps. This tech-
nique is being used
less because of the
availability of disposable, waterproof, adhesive
plastic sheets, applied circumferentially around
the extremity. In situations where disposable
drapes may not be available, the stockinette
method is still useful.
Removing sticky strips. The disposable adhe-
sive sheets have sticky strips that must be pulled
off. The ends of these strips can be difcult to
control, so they may become contaminated and
thus may contaminate drapes or gowns.
Contaminating the ends of sheets. When
circumferentially wrapping plastic sheets
around an extremity, great care must be taken
to prevent the ends of the sheets from becom-
ing contaminated and falling back onto the
eld. This can be remedied by rst covering
most of the table and arm boards with sterile
half-sheets. Then, after a scrubbed team
member places the extremity drape, another
scrubbed person inserts the extremity through
the incise hole and the rest of the extremity
drape is placed over previous drapes.
Clinicians moving in or around the sterile
eld should do so in a manner that does not
contaminate it. Nonscrubbed personnel should
maintain a distance of at least 12 inches from
all parts of and people in the sterile eld.
March 2010 Vol 91 No 3 HOPPERMOSS
358 AORN Journal
One scrubbed person placing the drapes.
Even with the help of the circulating nurse, it is
difcult for one scrubbed person to place the
drapes without breaking sterile technique. If at all
possible, draping should be a team task.
Moving a drape. During a procedure, it may
seem convenient to adjust the drapes for addi-
tional exposure. This should not be done. The
portion of the surgical drape that creates the ster-
ile eld should not be shifted or moved after it is
positioned; doing so can compromise the sterility
of the eld.
9
Passing off the suction tubing or ESU cords
improperly. A common error is for the suction
tubing or ESU cord to be passed off in such a
way that not enough length is left for use on the
sterile eld. It may be human nature to tug on the
cords to get more play, but this should not be
done. When a sterile item extends beyond the
sterile boundary, it is considered contaminated
and should not be pulled onto the sterile eld.
10
If there is any doubt about the sterility of an item,
the item should be replaced.
Suture, suction, or ESU active electrode
falling. Based on this same principle, if any
item falls beyond the sterile eld, it must be con-
sidered contaminated and, therefore, cannot be
brought back up onto the sterile eld.
10
Although
how far off the sterile eld is considered below
the eld may bring up the politics of contain-
ment, the prudent course of action is to remove
the item carefully from the sterile eld without
causing further contamination. A nonscrubbed
surgical team member then places it in a desig-
nated receptacle.
X-ray cassette draping. Draping an x-ray
cassette with a sterile plastic cover can be the
cause of a break in technique. Since the advent of
portable uoroscopy (ie, C-arm), two common
errors are possible: neglecting to drape the C-arm
and contaminating the drapes when swinging the
C-arm for a lateral image. To reduce the chance
of a break in technique, nonsterile equipment
should be covered with sterile barrier materials
before being introduced to or brought over a ster-
ile eld; sterile barrier material should be applied
to the portion of any nonsterile equipment that
will be positioned immediately adjacent to the
sterile eld.
9
Furthermore, staff members from the
radiology department should receive instruction
regarding the principles of aseptic technique to
help reduce the chance of a break in technique
(eg, proper cleaning of equipment before bringing
it into the OR from outside the restricted area of
the surgical suite).
15
Environmental Concerns
Numerous environmental concerns should be con-
sidered to ensure compliance with aseptic technique.
Some environmental concerns include dirt falling
from overhead lights, turbulent airow during sur-
gery, and bacterial shedding from personnel.
Dirt on lights. Dirt from overhead lights falling
into the incision may be inevitable, unless sterile
lighting is invented. Therefore, lights always
should be meticulously damp dusted before the
rst scheduled surgical procedure of the day and
after each procedure with a facility-approved hos-
pital detergent/disinfectant and water.
15
Turbulent airow during surgery. Turbulent
airow in the OR can increase the patients risk
of acquiring an SSI. In theory, talking can accel-
erate the eventual contamination of the mask.
Talking, as well as the number of people present
in the OR, should be kept to a minimum during
procedures. An increase in the amount of talking
and the number of people present can increase the
number of airborne microorganisms.
16
Open OR doors are conduits for potentially
contaminated air. Each surgical suite should have
strict rules about which doors should remain shut
unless entrance or exit is required. Directional
airow, positive air pressure, and use of high-
efciency particulate air (HEPA) lters help
mitigate this problem, but some older surgical
COMMON BREAKS IN STERILE TECHNIQUE www.aornjournal.org
AORN Journal 359
suites may not have all three components. Trafc
in and out of the OR should be kept to a mini-
mum. The doors to the OR should remain closed
except when personnel are entering or leaving or
patients, supplies, or equipment are being moved
in or out of the OR.
16
The air pressure in the OR
should be maintained under positive pressure
with a specied number of total room air ex-
changes per hour depending on the area in the
surgical suite.
17
Frequently opening and closing doors in the
OR also increases the risk of insects entering
the OR. Every OR
should have a proto-
col to handle this
sort of occurrence
because this can oc-
cur even when the
OR suite has sealed
windows or no win-
dows at all. Flies and
other insects manage to get into the surgical
suitethrough bay doors in the receiving area,
vents to the outside, or doors opened as people
enter the hospital. The principle of containment
starts with covering the incision with a hand
towel while efforts ensue to kill the insect or
move it out of the room. One trick to minimize
increased air turbulence when trying to catch a y
is to turn out all the lights except one that is
away from the sterile eld to lure the insect to the
light. Typically, these simple measures sufce. If
the problem becomes frequent, the infection con-
trol and plant operations personnel should be noti-
ed so that they can initiate an investigation. All
possible entrances to the facility should be evalu-
ated to identify potential problems (eg, the bay
doors in receiving being left open). A closed-door
policy in the surgical suite should be enforced.
Bacterial shedding. Dirty skin can release
microorganisms into the air. Keeping this in
mind, everybody in the OR, including observers
and anesthesia care providers, should cover their
skin as much as is practical. In the restricted ar-
eas of the surgical suite, surgical attire and hair
coverings are required.
16
Nonscrubbed personnel
should wear long-sleeved jackets that are buttoned
or snapped closed to prevent bacterial shedding
from bare arms.
18
Surgical Technique
Dead cells are a natural food source for bacteria,
which cause SSIs. Furthermore, antibiotics carried
in the bloodstream cannot reach necrotic tissue,
because it has no blood supply. Major sources of
tissue necrosis are
electrosurgery, re-
traction, and dissec-
tion. Other concerns
involving surgical
technique include
dealing with spray,
bone dust, and de-
bris; handing off
specimens; irrigating the surgical wound; and
avoiding sharps injuries.
Electrosurgery. In 1926, William T. Bovie, MD,
an American biophysicist, and Harvey Cushing,
MD, a neurosurgeon, developed electrosurgical
technology, thermal coagulation by electrical en-
ergy, to minimize intraoperative bleeding.
19
One
drawback of electrosurgery is the production of
char, a by-product of thermal coagulation. If bac-
teria are present in the wound, the addition of
charred tissue, a nutrient source for bacteria, is an
invitation for the bacteria to ourish. Therefore,
the scrub person should clean the active electrode
tip away from the incision frequently to remove
char and debris.
20
Electrosurgery has become indispensable in
modern surgery. Some surgeons use the cutting
modality of electrosurgery as a dissecting tool.
The higher current slices through the tissue and
coagulates at the same time, which may be pref-
erable to using a knife. This is especially true for
dissecting periosteum off bone or cutting through
Skin can release microorganisms into the air.
Keeping this in mind, everybody in the OR,
including observers and anesthesia care providers,
should cover their skin as much as is practical.
March 2010 Vol 91 No 3 HOPPERMOSS
360 AORN Journal
muscle. The char left behind in crevices created
by implants, metal, cement, or allografts, how-
ever, may create a possible focus of infection be-
cause no blood supply can get to it. Bacteria can
go into a state of suspended animation, protected
by a coat of bioslime (ie, a coating produced by
some bacteria that enables them to resist host
defenses like phagocytes).
21
Over time, the bacte-
ria can establish colonies in dead tissue.
21
Many
such colonies can be eradicated over time, espe-
cially in a healthy person. Occasionally, however,
one of the colonies may create an abscess, result-
ing in a deep wound infection.
This theory can offer one explanation for why
infections around implants can be so chronic.
Charnley believed that some painful joint replace-
ments could be caused by a low-grade infection.
22
The model for this is chronic osteomyelitis, where
bacteria lie dormant in bone and produce intermit-
tent are-ups. Electrosurgery should be used pru-
dently to avoid providing microorganisms in a
surgical incision with char, a ready nutrient sup-
ply. When electrosurgery is used, diligent irriga-
tion should be used to remove as much of the
char as possible.
Tissue retraction. Retractors facilitate expo-
sure of the surgical site but can cause tissue in-
jury and necrosis, which can produce detritus,
increasing the patients risk of infection. Even a
skin hook can kill cells when used for tissue ex-
posure. Although self-retaining retractors are very
helpful for surgeons, they have drawbacks. In
return for exposure, self-retaining retractors can
cause tissue necrosis and, with time, cell death,
especially if too much pressure is applied. In the-
ory, releasing the blades or teeth of the retractor
at periodic intervals eases the lack of blood sup-
ply to the tissues and gives the tissue a chance to
recover from the pressure. Releasing the self-
retaining retractor causes loss of surgical expo-
sure, however, so frequently this practice is not
possible or practical.
Dissection. Using a variety of instruments, the
surgeon begins dissection and develops tissue
planes for deep exposure. The surgeon uses for-
ceps and scissors to incise the fascia as well as
identify and spread or cut the muscle. He or she
may use electrosurgery to minimize muscle bleed-
ing. The surgeon may tie, clip, or coagulate ves-
sels. Whether the dissection is sharp (eg, scissors,
knife, electrosurgery) or dull (ie, ngers, peanuts,
elevators), cell death occurs.
Spray, bone dust, and debris. Any aerosol
produced during surgery should be dealt with cau-
tiously. Particles may rise in the air, touch unster-
ile surfaces, and fall back in. This is especially
true of bone debris when power tools are used.
The classic example is the high-speed burr, which
throws a spray of bone debris into the air. Power
lavage also can be a culprit. Overzealous spraying
can bring microorganisms back into the incision.
The lights over the eld are not far away and are
unsterile. Spray and debris can rise to touch the
surfaces and fall back. When possible, shields
(eg, lavage units) should be used to prevent the
aerosol from being dispersed away from the point
of use.
Handing off specimens. Specimens should be
handled carefully in a manner that protects and
secures the specimen and also prevents contami-
nation of the personnel handling the specimen.
23
Typically, the scrub person hands off the speci-
men to the circulating nurse. It is best for the
scrub person to pick up the specimen with an in-
strument (eg, forceps) and pass the instrument off
the eld with the tissue. Transferring the speci-
men into the specimen container with the inten-
tion of keeping the instrument presupposes that
the tissue will drop neatly off of the instrument.
More often, the tissue sticks to the instrument and
needs to be manipulated against the side of the
container, contaminating the instrument in the
process. It is best practice to pass off the tissue
and the instrument by placing both into the speci-
men container.
COMMON BREAKS IN STERILE TECHNIQUE www.aornjournal.org
AORN Journal 361
Irrigating the surgical wound. Although stud-
ies have not denitively determined whether it is
necessary to add antibiotics to irrigation solution,
this practice may be benecial. Irrigation rinses
away dead cells, blood, and bacteria and prevents
drying of the tissues. Bacteria, invisible to the
naked eye, may be settling in the wound through-
out the procedure. Irrigation is important during
the procedure, as well as during closure. Pausing
to irrigate at frequent intervals may help reduce
the patients risk of acquiring an SSI. This is par-
ticularly easy to accomplish when an interruption
in surgery occurs (eg, taking an x-ray, preparing
an implant).
Avoiding sharps injuries. The Occupational
Safety and Health Administration requires health
care facilities to protect their workers from expo-
sures to bloodborne pathogens and to have a writ-
ten exposure control plan.
24
The Occupational
Safety and Health Administration bloodborne
pathogen standard requires protection through the
use of universal precautions, engineering controls,
work practice controls, organizational controls,
and communication. It also mandates that em-
ployers maintain a log of injuries from contami-
nated sharps.
25
Personnel should report all expo-
sure incidents (eg, needle sticks and other blood
exposures) to the health care organization accord-
ing to the facility policy; prompt reporting allows
employers to provide timely and condential
postexposure evaluation, intervention, and testing
and appropriate prophylaxis.
26
One drawback of the bloodborne pathogen
standard is that because the protocol is time con-
suming, some employees may be reluctant to ad-
mit that a needle stick occurred. There are the
problematic issues of paperwork, time, and un-
wanted injections. Mini sticks, where there is a
question as to whether or not the needle really
penetrated, are often the result of using a curved
needle. When the problem is announced, the team
should freeze, dispose of the needle and suture in
a manner that maintains the surgical count, and
inspect the glove and affected hand. The incident
must be reported and protocols followed.
Bone sticks may accompany attempts to reduce
fracture fragments with ones gloved ngers. If at
all possible, instruments should be used to manip-
ulate the fragments, although there will always be
a situation during which the surgeon wants or
needs to hold a fragment of bone in place manu-
ally. Bone tamps should always be used when
tamping bone grafts down rather than doing it
manually with the ngers.
CONTAINING THE CONTAMINATION OF A
BREAK IN STERILE TECHNIQUE
What should be done if a break in technique has
occurred but time has elapsed before the break is
recognized (ie, a type 2 or type 3 break)? How
can the extent of contamination be determined?
How can the contamination be isolated and con-
tained? One recommendation is to institute the
use of a watchword, whereupon all surgical team
members freeze. Team members would then com-
municate the dilemma, discuss options, and iden-
tify and implement a solution so the procedure
can proceed. One facility implemented the FCC
plan: freeze, communicate, and contain, using the
watchword Boppo. The importance of freezing
is that when a break is discovered, no one moves,
which keeps the contamination from spreading.
Communication is crucial at this point. Different
options for resolution may be voiced, and all
opinions should be considered valid. The circulat-
ing nurse, scrub person, surgeon, assistants, and
anesthesia care provider all may have valuable
input. The team must reach a consensus on how
to proceed.
Consider the situation of a knife blade penetrating
a sterile drape. The rst person to notice the prob-
lem clearly says, Boppo, and all team members
freeze while the situation is assessed and options are
discussed. One team member might question
whether the area is contaminated because the knife
blade was sterile before it went through the sterile
March 2010 Vol 91 No 3 HOPPERMOSS
362 AORN Journal
drape. One team member might want to investigate
to determine how many layers of sterile drapes were
penetrated. How can this be accomplished safely
and efciently? The team might discuss this option
but decide that in the effort to determine the level of
contamination, drapes would have to be pulled up,
which would further spread the contamination. An-
other team member might suggest using scissors to
cut a wide patch out of the drape to see the extent
of the contamination. One team member might
question whether antibiotic prophylaxis is advisable.
In the end, the team decides that the basic principle
of sterile technique applies: if in doubt, treat it as
contaminated. Cooperatively, the team decides that
the knife blade and handle should be discarded im-
mediately, not placed on the Mayo stand or back
table, and the hole should be covered with a new,
impermeable drape. The team determines that addi-
tional antibiotics are not required because an antibi-
otic was administered 15 minutes before the initial
incision. At this point, the surgeon determines
whether it is safe to continue surgery.
Occasionally, heated disagreements may occur
regarding how to handle a break in technique. The
attending surgeon has the ultimate responsibility for
determining when to resume the procedure, but what
if the circulating nurse, scrub person, or an assistant
(eg, RN rst assistant) disagrees? The dictatorial
ways of the old-time surgeons and captain of the
ship philosophy have largely been modied by new
policies and changes in the workplace environment.
This has given rise to a healthier atmosphere in
which there is more of a team approach.
CORRECTIVE ACTION AND REPORTING
When a break in sterile technique occurs and cannot
be rectied, appropriate corrective actions should be
implemented immediately unless doing so would
compromise the patients safety. If the patients
safety would be at risk, the break should be cor-
rected as soon as it is safe to do so.
9
In these situa-
tions, the policies and procedures of the health care
facility should specify how to report the break in
sterile technique to appropriate risk management
personnel and how to revise the wound classica-
tion after a break in sterile technique occurs.
9
CONCLUSION
For the surgical patient, acquiring an SSI leads to
needless discomfort and treatments, as well as an
increased hospital stay. For the health care facil-
ity, an SSI also means additional cost. A break in
sterile technique is one potential cause of an SSI.
As patient advocates, all members of the periop-
erative team must
have a good surgical conscience;
be knowledgeable about the principles of ster-
ile technique;
remain vigilant to prevent and identify breaks;
and
initiate appropriate corrective actions as soon
as possible after a break is realized.
With this knowledge and skill, each member of
the perioperative team can proactively reduce the
adverse effects of a break in sterile technique and,
consequently, an SSI, ultimately improving the
patients surgical outcome.
References
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10. Nicolette LH. Infection prevention and control in the
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William R. Hopper, MD, FAAOS, is a retired
attending orthopaedic surgeon, AO Fox Memo-
rial Hospital, Oneonta, NY. Dr Hopper has no
declared afliation that could be perceived as
a potential conict of interest in publishing this
article.
Rose Moss, RN, MN, CNOR, is an indepen-
dent nurse consultant, Hendersonville, NC.
Ms Moss has no declared afliation that could
be perceived as a potential conict of interest
in publishing this article.
March 2010 Vol 91 No 3 HOPPERMOSS
364 AORN Journal
CONTINUING EDUCATION PROGRAM
3.4
Common Breaks in Sterile Technique:
Clinical Perspectives and Perioperative
Implications
PURPOSE/GOAL
To educate perioperative nurses about identifying and preventing common breaks in
sterile technique.
OBJECTIVES
1. Identify sources of surgical site infection.
2. Identify common breaks in sterile technique.
3. Describe means to prevent common breaks in sterile technique.
The Examination and Learner Evaluation are printed here for your convenience. To
receive continuing education credit, you must complete the Examination and
Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Transient ora
1. are considered to be permanent residents of the
skin.
2. are easily transmitted to hands from patients
and inanimate surfaces.
3. can be removed by hand washing or use of a
hand rub agent.
4. are not readily removed by hand washing.
5. colonize the supercial layers of the skin.
a. 1 and 4 b. 2, 3, and 5
c. 1, 2, 3, and 5 d. 1, 2, 4, and 5
2. The risk of a surgical site infection increases with
the dose of bacterial contamination and the viru-
lence of the bacteria.
a. true b. false
3. A type 3 break in sterile technique is one that is
a. recognized immediately.
b. recognized shortly after occurrence.
c. recognized at a later time.
d. not recognized at all.
4. To ensure that items used within the sterile eld
are sterile, perioperative personnel preparing an
OR for a procedure must inspect all items imme-
diately before they are presented to the sterile
eld for
1. an intact seal.
2. correct processing.
3. inclusion of the proper sterilization indicator.
4. package container integrity.
5. proper packaging.
a. 1 and 3 b. 2, 3, and 5
c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
EXAMINATION
AORN, Inc, 2010 March 2010 Vol 91 No 3 AORN Journal 365
5. There is no specied amount of time that a setup
can remain open and unused and still be consid-
ered sterile because the sterility of an open eld
is event related.
a. true b. false
6. For surgical skin prep,
a. rapid, gentle washing is recommended.
b. the longer the skin is prepped, the better.
c. vigorous scrubbing is recommended.
7. Turbulent airow can be caused by
1. excessive talking.
2. frequent opening and closing of the OR doors.
3. an increased number of personnel in the OR.
4. directional airow, positive air pressure, and
use of high-efciency particulate air (HEPA)
lters.
a. 1 and 2 b. 2 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
8. Char
1. is a by-product of thermal coagulation.
2. is a nutrient source for bacteria.
3. should frequently be cleaned off the active
electrode tip.
a. 1 b. 1 and 3
c. 2 and 3 d. 1, 2, and 3
9. The policies and procedures of a health care fa-
cility should specify how to
1. report the break in sterile technique to appro-
priate risk management personnel.
2. discipline the individual responsible for the
break in technique.
3. revise the wound classication after a break in
sterile technique occurs.
a. 1 b. 1 and 3
c. 2 and 3 d. 1, 2, and 3
10. As patient advocates, all members of the periop-
erative team must
1. be knowledgeable about the principles of ster-
ile technique.
2. have a good surgical conscience.
3. initiate appropriate corrective actions as soon
as possible after a break is realized.
4. remain vigilant to prevent and identify breaks.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor,
with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell
have no declared afliations that could be perceived as potential conicts of interest in publishing this article.
March 2010 Vol 91 No 3 CE EXAMINATION
366 AORN Journal
CONTINUING EDUCATION PROGRAM
3.4
Common Breaks in Sterile Technique:
Clinical Perspectives and Perioperative
Implications
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. Identify sources of surgical site infection.
Low 1. 2. 3. 4. 5. High
2. Identify common breaks in sterile technique.
Low 1. 2. 3. 4. 5. High
3. Describe means to prevent common breaks in
sterile technique.
Low 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
5. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
7. Will you change your practice as a result of
reading this article? (If yes, answer question
#7A. If no, answer question #7B.)
7A. 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 phy-
sicians to seek their input and acceptance of
the need for change.
4. I will implement change and evaluate the ef-
fect of the change at regular intervals until the
change is incorporated as best practice.
5. Other:
7B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of this 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
the change.
4. Other:
8. Our accrediting body requires that we verify the
time you needed to complete this 3.4 continuing
education contact hour (204-minute) program:
This program meets criteria for CNOR and CRNFA recertication, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
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.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.
Event: #10011; Session: #4003 Fee: Members $17, Nonmembers $34
The deadline for this program is March 31, 2013.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each
applicant who successfully completes this program will be able to print a certicate of completion.
LEARNER EVALUATION
AORN, Inc, 2010 March 2010 Vol 91 No 3 AORN Journal 367