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
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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 identified in an
AORN member survey.
2. Identify methods to mitigate the risks of injury posed by
the identified patient safety issues.
Accreditation
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
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AORN, Inc, 2013
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cation, as well as other continuing education requirements.
AORN is provider-approved by the California Board of
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Conflict of Interest Disclosures
As a consultant of RF Surgical Inc, Dr Steelman has declared
an affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article. Dr Graling
has no declared affiliation that could be perceived as posing
a potential conflict of interest in the publication of this article.
The behavioral objectives for this program were created
by Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have
no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as continuing education
for registered nurses. This recognition does not imply that
AORN or the American Nurses Credentialing Center approves
or endorses products mentioned in the activity.
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 identified the top 10 safety issues reported by
perioperative nurses. These nurses are in a unique position to understand the errors and
the unreported near misses that occur in the OR. For each of the top-rated safety issues
that RNs identified, we discuss the evidence of risk and contributing factors and make
targeted recommendations for further improvement in perioperative safety with
the goal of mitigating risk and improving patient outcomes. AORN 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 patients5; other near
misses are unreported. Many adverse events and
near misses occur during care of the surgical pa-
tient. The complexities of the surgical procedure,
anesthesia, technology, and teamwork increase
patient risk during the perioperative experience.
Perioperative RNs are in a unique position to
understand the adverse events and unreported near
misses that occur every day. In December 2011, we
surveyed AORN members to determine what they
consider the highest-priority patient safety issues
that currently need to be addressed. We received
3,137 usable completed surveys.6 For the top 10
safety issues identified, we solicited anecdotal re-
ports from nurses that provided us with a more
thorough understanding of factors that contribute
to these safety issues and that allowed us to develop
targeted recommendations for improvement. The
purposes of this paper are to
n review the top 10 patient safety issues identified
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 five highest priorities to
address.6 This may be somewhat surprising because
of the longevity of national initiatives to prevent this
“never event.” In 1998, The Joint Commission first
recommended marking the surgical site and using
a verification checklist.7 Wrong site/procedure/
patient surgery is estimated to occur 40 times per

http://dx.doi.org/10.1016/j.aorn.2013.04.012
680 j AORN Journal
June 2013 Vol 97 No 6
AORN, Inc, 2013
TOP 10 PATIENT SAFETY ISSUES
TABLE 1. Top 10 Safety Issues Identified by
1 modified for facility use.
Perioperative RNs (N [ 3,137)
Safety issue
1. Preventing wrong site/procedure/patient surgery
2. Preventing retained surgical items
3. Preventing medication errors
4. Preventing failures in instrument reprocessing
5. Preventing pressure injuries
6. Preventing specimen management errors
7. Preventing surgical fires
8. Preventing perioperative hypothermia
9. Preventing burns from energy devices
10. Responding to difficult intubation or airway
emergencies
1. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety
issues identified by perioperative nurses. AORN J. 2013;97(4):402-418.
week8 and remains the second most commonly re-
ported sentinel event to The Joint Commission.9
The Joint Commission has identified risk points
in processes where wrong-site surgery can be pre-
vented, including scheduling errors, verification
errors, distractions/rushing, inconsistent site mark-
ing, no safety culture, and time-out errors.8 Re-
searchers observing procedures in eight facilities
in Minnesota identified inconsistencies in site
marking (eg, no mark, mark made in the OR,
marks that were obscured or ambiguous, marks
made without referencing source documents) and
time-out procedures (eg, no time out, not ceasing
activity, using memory rather than documents,
surgeon not present) as contributing factors to
wrong site surgery.10
What More Can We Do?
Based on this evidence, we can make recommen-
dations for further action to help prevent wrong site/
procedure/patient surgery. First, to improve the ac-
curacy of information on the surgery schedule, peri-
operative nurses should collaborate with scheduling
personnel from surgeons’ offices to implement a
checklist for scheduling surgery. The Pennsylvania
Patient Safety Authority (PPSA) has a checklist for
www.aornjournal.org
office schedulers11 and OR schedulers12 that can be
The preoperative nurse should verify that all
% necessary documents (eg, consent, history and
physical examination report, orders, OR schedule)
69
61
are available, and the surgeon should verify and
43 mark the site using these documents. The patient
41 should not be transferred into the OR until this
40 is complete.
35
35
Next, nurses should
31 n strictly enforce adherence to the time out,
26
n avoid workarounds that decrease the effective-
23
ness of this safety measure, and
n not tolerate deviations or lack of engagement of
team members.
We must place a “hard stop” on interruptions dur-
ing the time out and should not rely on memory
during this verification. It is essential that nurses
speak up when they are concerned about any safety
issue. When more than one procedure is being
performed by the same surgeon, the site and later-
ality should be confirmed before each procedure.
The entire time-out process should be repeated
when there is a change of surgeon.8
The PPSA has identified best practices for reli-
able performance of the Universal ProtocolTM 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 radiologist’s interpretation of the image in addi-
tion to the surgeon’s.
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).
AORN Journal j 681
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Furthermore, the quality management program
should include a comparison of policies and pro-
cedures (ie, gap analysis) with recommendations
of both The Joint Commission and the PPSA.
In June 2004, AORNdwith the support of The
Joint Commission, the World Health Organization,
and the Council on Surgical and Perioperative
Safetydinitiated National Time Out Day to sustain
and promote progress in preventing wrong site/
procedure/patient surgery.14 Perioperative nurses
should use this annual campaign as a mechanism to
raise awareness within their facilities, to reenergize
efforts, and to engage other disciplines regarding
the Universal Protocol process.
2. PREVENTING RETAINED SURGICAL
ITEMS
Sixty-one percent of the nurses who were surveyed
identified preventing retained surgical items to be
a high priority.6 Retained items are estimated to
occur in 1 in 5,550 surgeries.15 The National Quality
Forum considers retained surgical items to be se-
rious reportable events,16 and this was the sentinel
event most frequently reported to The Joint Com-
mission for the past three years (ie, 133, 188, and
115 events voluntarily reported).9
A health care failure mode and effect analysis
identified 43 high-risk failures that can occur dur-
ing management of sponges, providing insight into
how these events can occur and where controls
are needed for successful prevention. The most
frequently identified causes of these potential fail-
ures include distraction, multitasking, not following
the facility’s count procedure, and time pressure
(Table 2).17
What More Can We Do?
Based on this evidence, we can make recommen-
dations for prevention of retained surgical items.
First, perioperative nurses should minimize dis-
tractions and multitasking while managing counted
items (eg, adding and removing items from the
sterile field, counting). Before counting, the nurse
should alert the team that the count will be starting.
682 j AORN Journal
STEELMANdGRALING
TABLE 2. Causes of High-Risk Failures in
1
Preventing Retained Surgical Sponges
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.
This allows other urgent tasks to be prioritized.
Perioperative nurses also should actively enforce
the facility’s procedures for managing counted
items. Unfortunately, distraction, multitasking,
and time pressure are inherent in the work in an
OR and are difficult to control.
AORN’s “Recommended practices for preven-
tion of retained surgical items” was significantly
revised in 2011 and includes recommendations
focusing on a multidisciplinary approach to pre-
vention. The recommendations state that “peri-
operative staff members may consider the use of
adjunct technologies to supplement manual count
procedures.”18(p314) Adjunct technology provides
the needed control for the causes of potential fail-
ures in managing surgical sponges (eg, distraction,
multitasking, time pressure).
Nurses should participate in evaluating and
selecting adjunct technology, and they should
consider the ability of technological devices to
detect failures in managing sponges. The cost of
purchasing adjunct counting technology may be
offset by the reduction in OR time spent resolving
TOP 10 PATIENT SAFETY ISSUES
incorrect counts, intraoperative radiographs for
incorrect counts, and the additional patient care
related to retained items. A multidisciplinary
team should review and revise facility policies
and procedures to reflect the new AORN recom-
mendations.
3. PREVENTING MEDICATION ERRORS
Overall, 43% of all nurses surveyed and two-thirds
of nurses working in ambulatory surgery centers
(ASCs) identified preventing medication errors to
be a high priority.6 The higher percentage in ASCs
likely reflects the lack of available resources in that
setting compared to the resources that are typically
provided by hospital pharmacies. Although the
actual number of medication errors that occur
each year is unknown, medication errors resulting
in death or serious injury were the ninth most
frequently reported sentinel event to The Joint
Commission in 2012.9 The PPSA reviewed 502
medication error reports from ASCs between 2004
and 2010.19 The most common types of errors
reported were medication omission, wrong medi-
cation, monitoring error, and administering a med-
ication for which there was a documented allergy.
The most common routes of administration asso-
ciated with errors were IV, ophthalmic, and oral.
The most common classes of medications associ-
ated with errors were antibiotics (33.9%), local
anesthetics (8%), corticosteroids (4.6%), opioid
analgesic combinations (4.6%), benzodiazepines
(4.2%), and nonsteroidal anti-inflammatory agents
(3.8%). The most common medications associ-
ated with errors identified were cefazolin (15.3%),
vancomycin (4%), and midazolam (4%).
Some of the issues involved with perioperative
medication safety include
n adult versus pediatric dosing,
n lack of standardization,
n unnecessary variability of doses,
n verbal orders,
n lack of labeling and communication about
medications,
www.aornjournal.org
n use of surgeon’s preference cards for preparing
medications, and
n tolerance of non-approved abbreviations.
In ASCs, specific contributing factors include
communication failures or overlooking preopera-
tive orders, choosing the wrong ophthalmic medi-
cation, failing to label medications on the sterile
field, and relying on color coding rather than
medication labels.19
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 field. This service minimizes
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June 2013 Vol 97 No 6
distractions and contamination when medications
are being mixed and dispensed onto the sterile field.
We need to make a concerted effort to minimize
verbal orders by implementing standard order sets
and implementing briefings with the surgeon before
each procedure. We should no longer use surgeon
preference cards to identify doses because many
surgeons are actually unaware of what information
is on the preference cards. Instead, we should re-
place this practice with the use of physician order
sets. We need to strictly enforce labeling of medi-
cations and solutions that are removed from their
original containers and communicating with the
surgeon when handing off medications. We need
to strictly practice the seven rights of medication
safety: right patient, medication, dose, time, route,
reason, and documentation.22 Lastly, we need
to enforce a hard stop on using non-approved
abbreviations.
4. PREVENTING FAILURES IN
INSTRUMENT REPROCESSING
Overall, 41% of the perioperative nurses identified
preventing failures in instrument reprocessing to
be a high priority for action; 48% of nurses working
in ASCs and 59% of nurses in federal hospitals
rated this issue a high priority.6 These differences
likely reflect the limited resources in ASCs com-
pared to hospitals and a large federal initiative in
the Veterans Administration to improve endoscope
reprocessing.23 Reporting of reprocessing failures
is not federally mandated, so the extent of this
problem is unknown and errors have gone unre-
ported. In an effort to achieve transparency in
recent years, more than 15,000 patients were of-
fered infectious disease testing after failures 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
684 j AORN Journal
STEELMANdGRALING
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,
TOP 10 PATIENT SAFETY ISSUES www.aornjournal.org

n is equipped with a variety of tools necessary to be strictly followed. For example, the state of New
effectively clean instruments in a manner Jersey requires that sterile processing department
consistent with the manufacturer’s IFU, and technicians be certified to demonstrate reprocessing
n is stocked with personal protective equipment to competencies,29 and several other states have sim-
minimize exposure to contaminants. ilar bills in process. At a minimum, staff member
competency should be evaluated and documented
Furthermore, manufacturers’ IFU should be readily
for each type of surgical instrument and every type
available in the decontamination area and consis-
of flexible endoscope that is reprocessed in the
tently followed. Trays of instruments should be
clinical setting.
cleaned in a mechanical washer decontaminator
Ongoing quality control monitoring should be
unless contraindicated by the IFU.
conducted on every reprocessing cycle. This quality
Reprocessing instruments in the OR is high risk
control requires comprehensive documentation to
because time pressures encourage personnel to
allow instruments to be traced to individual patients.
circumvent the rigor required for effective reproc-
Each detail of reprocessing should be documented,
essing. Personnel may feel pressure to cut corners
and routine audits of compliance with procedures
in the cleaning process or may wear OR scrubs into
and IFU should be performed. An ongoing quality
the decontamination area and then back into an OR.
improvement program should be in place to evaluate
Adequate training for and competency evaluation
the reprocessing of instruments between procedures
of the various people who might be asked to per-
and any incidents of noncompliance with national
form the reprocessing is difficult to achieve.
recommendations. This type of program includes
AORN recommends that immediate use steam
setting clear expectations of appropriate reprocess-
sterilization (IUSS) only be used when there is
ing; ensuring competency of personnel; reviewing
insufficient time to sterilize in a wrapped tray or
internal data; and implementing corrective actions
container for instruments that are subjected to the
when necessary, such as purchasing additional in-
same decontamination standards as other instru-
struments or retraining personnel.
ments and not be used in lieu of an adequate
In 2011, the Association for the Advancement
instrument inventory.27 Immediate use steam ster-
of Medical Instrumentation and the US Food and
ilization should only be performed if
Drug Administration convened a summit to discuss
issues and priorities for action related to reproc-
n the manufacturer’s IFU include instructions
essing. This summit reinforced the basics of in-
for IUSS,
strument reprocessing in health care facilities
n the IFU are available and followed,
(Table 3).26
n items are placed in a container validated and
Issues related to failures in instrument re-
cleared by the US Food and Drug Administra-
processing have been discussed for decades.
tion for IUSS,
However, recent events23-25 have raised the level
n the container manufacturer’s IFU are followed,
of concern and instilled a sense of urgency for
n measures are taken to prevent contamination
action and an incentive for change. Perioperative
during transfer to the sterile field, and
nurses should take advantage of this sense of
n the sterilized items are not stored.27
urgency to garner administrative support to fa-
Instrument reprocessing should only be per- cilitate improvements in their practice settings,
formed by trained personnel who have demonstrated including support for allocating the resources
competencies in reprocessing the variety of devices necessary to come into compliance with national
used in the clinical setting. State regulations must recommendations.

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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.

5. PREVENTING PRESSURE INJURIES Concentration of pressure on the small surface of

Overall, 40% of the nurses surveyed identified
preventing pressure injuries as a high priority,
particularly nurses in large (53%) or academic
hospitals (55%) as opposed to ASCs (17%).6 This
is likely because of the differences in procedure
duration in these settings.
More than one million people develop hospital-
acquired pressure ulcers each year,30 and 25% of
these injuries are associated with the OR.31 The
National Quality Forum considers stage III or IV
health care-acquired pressure injuries to be serious
reportable events.16
Pressure injuries are caused by inadequate tissue
perfusion, usually over a bony prominence, which
results from pressure or a combination of pressure
and shearing. The long duration of immobility dur-
ing surgical procedures places patients at increased
risk. Impaired circulation from peripheral vascular
disease and hypotension during surgery also de-
crease perfusion. Furthermore, devices used intra-
operatively to prevent blood flow to the surgical site
(eg, tourniquet, vascular clamps) prevent blood flow
to distal tissue (eg, heels).
The heel is the most common location of the more
serious pressure injury (ie, deep tissue injury).32
the heel, coupled with impaired circulation, makes
this tissue especially vulnerable to injury during
surgery. The incidence of heel pressure injuries
has been found to be 17% after orthopedic33 and
29.5% after cardiac surgery.34
What More Can We Do?
Our efforts to prevent intraoperatively acquired
pressure injuries start with an adequate preoperative
skin assessment. Nurses should be knowledgeable
about the risk factors for and the pathophysiology
of pressure injuries as well as the effectiveness
of pressure-dispersing surfaces. Nurses should use
these devices appropriately to disperse pressure
on affected body parts. When planning care for
a severely debilitated patient or someone with a
preexisting pressure injury, perioperative 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

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TOP 10 PATIENT SAFETY ISSUES
personnel are required to lift the patient’s buttocks
rather than dragging the patient into position.
Then the perioperative nurse must ensure that
pressure on the patient’s heels is eliminated. The
National Pressure Ulcer Prevention Advisory Panel
(NPUPAP) and the European Pressure Ulcer Ad-
visory Panel (EPUAP) recommend elevating the
heels completely, which redistributes the weight
of the leg along the calf, without putting all the
pressure on the Achilles tendon.36 The knee should
be flexed slightly, because hyperextension can
cause occlusion of the popliteal vein, which in-
creases the potential for deep vein thrombosis.37,38
This expectation should be clarified in facility
policies and procedures.
Lastly, perioperative nurses should collaborate
with wound ostomy nurses to review internally
collected data about pressure injuries and take
corrective action based on this evidence. The pres-
sure injury risk assessment tools that are currently
available do not focus on potential intraoperative
risk factors, such as positioning and duration of
surgery. AORN has established a task force that
is developing a risk assessment tool for intraoper-
atively acquired pressure injuries. When a valid and
reliable tool to assess risk is available, 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-five percent of the nurses responding to our
survey identified prevention of specimen manage-
ment errors to be a high priority for action.6 Nurses
working in larger hospitals (ie,  100 beds) prior-
itized this issue more often (34.8% to 39.3%) than
nurses in smaller hospitals (28.6%). This difference
may reflect the complexity of surgeries performed
and the number of specimens per procedure in the
large-hospital setting.
Specimen management errors are not publicly
reported; however, researchers in a large East Coast
hospital studied surgical specimen errors during
www.aornjournal.org
a six-month period.39 They found the incidence of
surgical specimen identification errors (eg, spec-
imen not labeled; empty container; incorrect later-
ality, tissue site, patient; no patient name; no tissue
site) was 4.3 in 1,000, and more than half were
associated with biopsy procedures.
Specimen management errors are very serious
and can lead to a delay in care, the need for reop-
eration, a failure to receive appropriate therapy, and
a lack of confidence in the quality of the facility
and the providers’ delivery of patient care. Anec-
dotal reports from perioperative nurses indicate that
contributing factors may include communication
failures in the OR, time pressure, interruptions, and
using preprinted labels from a previous patient.
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-
fication before sending the specimen out of the
OR. Communication about specimens should be
included in a preoperative briefing with the sur-
geon. AORN’s Comprehensive Surgical Checklist,
based on recommendations from The Joint Com-
mission and the World Health Organization, in-
cludes a briefing and debriefing model that can
be modified for use in the facility (Figure 1).40
By knowing what specimens can be anticipated,
the circulating nurse can minimize the time pressure
for specimen handling during the procedure. Spec-
imens should be labeled with two unique identi-
fiers.3 If preprinted patient labels are used, the nurse
should verify the accuracy of information on each
label as it is used and should ensure that unused
labels are removed from the room at the end of
the procedure. Multitasking during specimen man-
agement should be avoided. Lastly, a debriefing
with the surgeon at the end of the procedure
should include reviewing the identification of
specimens that were obtained and of the fixative
that was used. Before transferring the specimen
out of the OR, two people should verify the label
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Figure 1. The AORN Comprehensive Surgical Checklist, which includes a briefing, time out, and debriefing to enhance patient safety, can be modified for
the individual practice setting. Copyright ª 2012, AORN, Inc. All rights reserved. Reprinted with permission.
TOP 10 PATIENT SAFETY ISSUES
and contents, similar to the verification procedure
for blood products.39
Specimen management should be included in the
facility’s quality management programs and should
be investigated through a prospective risk assess-
ment, such as a health care failure mode and effect
analysis.41 This analysis should include all steps
in specimen management, including handling and
processing. By identifying potential failures and
their causes in the practice setting, this tool facilitates
prioritization of additional preventive measures.
7. PREVENTING SURGICAL FIRES
Preventing surgical fires was rated a high priority
by slightly more than one-third of respondents,
regardless of practice setting.6 This is likely be-
cause of the seriousness of related outcomes. The
ECRI Institute estimates that there are between
550 and 650 surgical fires each year in the United
States, and most are associated with the presence of
an oxygen-enriched atmosphere under the surgical
drapes.42
This phenomenon occurs when oxygen is de-
livered through an open source, such as nasal prongs
or an uncuffed endotracheal tube. Recent anecdotal
reports indicate that the use of antimicrobial prep
agents containing alcohol has increased dramati-
cally. Use of these agents, accompanied by time
pressure, increases the risk of surgical fires. Often,
there is inadequate communication among members
of the surgical team about the risk of fire, so the
person using the ignition source may be unaware
of an open oxygen source or alcohol fumes.
What More Can We Do?
The US Food and Drug Administration has devel-
oped comprehensive recommendations for prevent-
ing surgical fires.43 We recommend implementing
these recommendations as part of a fire safety
program:
n provide multidisciplinary training and drills,
n perform a fire risk assessment before making
the initial incision,
www.aornjournal.org
n communicate about the use of an open source of
oxygen or flammable prep agent before making
the incision,
n allow ample time for flammable prep agents to
dry, and
n holster the electrosurgery pencil when it is not
in use.
Conducting a fire risk assessment is extremely
important and should include aspects uniquely re-
lated to the specific procedure (Table 4). Fire
safety should be openly discussed during the
briefing before every procedure; risks should be
clearly communicated, and actions that should be
taken to mitigate these risks should be discussed.
Because of the seriousness of surgical fires, this
program also should include ongoing monitoring
of compliance. The Fire Safety Tool Kit,44 avail-
able as a free member benefit from the AORN
web site, contains tools to assist in proactively
promoting fire prevention, planning effective re-
sponse strategies, and developing department-
specific policies and protocols to protect patients
and staff members.
8. PREVENTING PERIOPERATIVE
HYPOTHERMIA
Overall, 31% of nurses in our study rated preven-
tion of perioperative hypothermia to be a high
priority.6 Staff nurses and registered nurse first
assistants (RNFAs) were more likely than others
to identify this issue as a problem (35.7% versus
26.5%). This difference might be explained by
the focus of their job responsibilities. Nurses pro-
viding indirect patient care might be focusing on
rates of compliance with reported process perfor-
mance measures and consider this safety issue
to be adequately addressed. Nurses providing
direct patient care may be focusing on individ-
ual patient outcomes and recognize the need for
additional focus.
All anesthetized surgical patients are at risk
for becoming hypothermic.45 Perioperative hypo-
thermia is a safety issue because hypothermia
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TABLE 4. Preoperative Briefing: Fire Risk Assessment Questions and Elements of Mitigation

1. Is oxygen or nitrous oxide being openly administered (eg, uncuffed endotracheal tube, nasal prongs, mask)?
Mitigation:
n Configure surgical drapes to allow sufficient venting.

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

n Titrate oxygen to the lowest percent necessary.

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

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

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

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

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

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

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

n Place wet sponges or towels around the surgical site.

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

n Place the light source in standby mode or turn it off when it is not in use.

n Inspect light cables before use and remove them from service if broken light bundles are visible.

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

Mitigation:
n Prevent pooling of skin prep solutions.

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

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

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

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

disconnected.
4. Is the surgical procedure being performed above the xiphoid process?
Mitigation:
n Coat the head and facial hair near the surgical site with water-soluble lubricant to decrease flammability.

n Use an adhesive incise drape.

n Do not use the ESU electrode to open the airway (eg, trachea, bronchus).

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

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

upper chest procedures.

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

n increases the risk of a postoperative surgical site No national database exists to report the inci-
infection,46 dence of perioperative hypothermia; however, a
n triples the risk of a morbid cardiac event literature review published in 2012 estimates
occurring,47 the incidence to be as high as 70% of surgical
n causes coagulopathy and the need for patients.53 The National Quality Forum has en-
transfusion,48,49 dorsed a process standard for perioperative tem-
n extends the duration of neuromuscular blocking perature management,54 originally part of the
agents,50,51 and Surgical Care Improvement Project (SCIP). This
n delays recovery.52 performance measure requires either the use of

690 j AORN Journal

TOP 10 PATIENT SAFETY ISSUES
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 fluids, and including
measurement of patient outcomes as part of a quality
management program. Patients should be actively
warmed preoperatively for at least 30 minutes to
minimize the temperature gradient between the core
and peripheral tissues and to prevent redistribution
hypothermia on induction of anesthesia.55 Preoper-
ative warming with warmed cotton blankets is inef-
fective at preventing hypothermia56 and should be
replaced with active warming in the preoperative
area that is restarted immediately on arrival in the
OR. Using preoperative active warming in addition
to intraoperative active warming has been found to
be more effective at maintaining normothermia than
use of active warming intraoperatively alone.57-59
In addition to using active warming preopera-
tively, patients should be warmed 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 manufacturer’s 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.
www.aornjournal.org
Warmed IV fluids should be used in addition to
FAW to minimize heat loss when more than 1 L of
fluid or refrigerated fluid is administered. Admin-
istering cool IV fluids increases heat loss; admin-
istering 1 L of room temperature solution decreases
the mean body temperature by 0.25 C (0.45 F).61
Patients often receive more than 1 L of IV fluid
during surgery, compounding this decrease. Pre-
warming IV fluids in a warming cabinet or using
an inline fluid warmer mitigates heat loss. Surgical
patients who receive warmed IV fluids have been
found to have 0.4 C to 0.9 C (0.72 F to 1.62 F)
higher core temperatures than those receiving room
temperature fluids.61-65 The amount of heat trans-
ferred by using prewarmed IV solutions is inade-
quate alone to prevent hypothermia, however. In
one study, 32% of subjects receiving room tem-
perature IV fluids were hypothermic on arrival in
the postanesthesia care unit, compared with 14% of
those receiving warmed IV fluids.62 In addition
to evaluating compliance with the SCIP quality
performance measure for external reporting, we
recommend that perioperative quality management
programs include evaluating compliance with three
evidence-based practicesdpreoperative FAW, in-
traoperative FAW, warmed IV fluidsdand patient
outcomes to determine the effectiveness of inter-
ventions used.
9. PREVENTING BURNS FROM ENERGY
DEVICES
More than 25% of nurses surveyed identified pre-
vention of burns from energy devices to be a pri-
ority issue.6 In ASCs, this issue was more likely to
be an identified priority than in hospitals (31.9%
versus 25.3%). The reason for this difference 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
June 2013 Vol 97 No 6
of electrosurgery burns result from direct coupling
when the electrosurgery unit is inadvertently acti-
vated.67 Some of these burns resulted from not
placing the active electrode in the holster when it
was not in use. Capacitive coupling has resulted
from insulation failure and the electrode touching
a metal instrument.68 Another energy device that
may lead to patient injury is the phacoemulsifier
used in cataract surgery. More than 1,400 corneal
burns during phacoemulsification have been re-
ported.69 Insufficient irrigation fluid can lead to
overheating of the probe and burns to surrounding
tissue. Contributing factors to burns from phacoe-
mulsifiers include a lack of familiarity with the
irrigation and aspiration equipment, the surgeon’s
lack of experience with the equipment, and human
error.69 Anecdotal reports from nurses also indicate
that the dimmed lights in the OR during ophthalmic
surgery in particular make it difficult to view the
aspirating fluid level.
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 manufacturer’s 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 phacoemulsification, an irrigation fluid
chamber monitor with an alarm that alerts per-
sonnel to low fluid levels should be used. An extra
bottle of fluid should be readily accessible in the
OR for immediate use. Supplemental lighting
should be available in the OR and should be used
to assist with visual inspection of fluid levels and
692 j AORN Journal
STEELMANdGRALING
operating equipment. The facility’s perioperative
quality management program should include poli-
cies for documenting education and competency
for each energy device used.
10. RESPONDING TO DIFFICULT
INTUBATION OR AIRWAY EMERGENCIES
The 10th priority perioperative patient safety issue
that surveyed nurses identified was responding to
difficult intubation or airway emergencies.6 Over-
all, 23% of nurses identified this patient safety issue
as a high priority for additional action. A higher
percentage of nurses working in ASCs identified
this issue than those working in hospitals (29.6%
versus 22.1%), and nurses working in smaller
hospitals were more likely to identify this issue
than those working in larger hospitals (25.0% to
26.9% versus 16.0% to 21.3%). This is likely be-
cause larger hospitals have more resources with
which to respond to airway emergencies than ASCs
and small hospitals.
The PPSA first identified management of difficult
airways as a safety issue in 2009, after reviewing 36
reports of anesthesia-related complications associ-
ated with difficult intubations.70 Of these reports,
nearly two-thirds were unanticipated difficult intu-
bations. Problems with endotracheal intubation can
result in hypoxia and brain damage and are the most
common cause of anesthesia-related deaths.71
Anecdotal reports from perioperative nurses
indicate that factors that deter an effective team
response to an unanticipated difficult airway in-
clude equipment being located in more than one
place, personnel being unfamiliar with equipment,
having no predetermined plan of action or defined
roles, and having difficulty obtaining expert assis-
tance. There also is the potential for making the
assumption that patients in ASCs are healthy pa-
tients who are low risk and personnel are mentally
unprepared to respond.
What More Can We Do?
Perioperative nurses should collaborate with anes-
thesia professionals, otolaryngologists, and nurses
TOP 10 PATIENT SAFETY ISSUES
in other areas in which anesthesia is administered
to develop a comprehensive and institution-wide
difficult airway management program. This pro-
gram should include
n a list of equipment to be stocked,
n a preanesthesia risk assessment,
n discussion of the airway management plan
during preoperative briefings,
n designation of a rapid response team, and
n regularly scheduled multidisciplinary education
and simulation drills.
The American Society of Anesthesiologists “Prac-
tice guidelines for management of the difficult
airway,” which includes the difficult airway algo-
rithm,72 should be used as a starting point 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 difficult airway cart or tool
case should include, at a minimum, a flexible fiber-
optic bronchoscope, a light source, laryngeal mask
airways, airway exchange catheters, and a crico-
thyroidotomy kit. Anesthesia professionals should
be the primary decision makers for what equipment
and supplies are purchased and stocked in this
cart or tool case. The University of California,
San Diego, has a virtual difficult airway manage-
ment cart that can be used as a resource.73 Anes-
thesia assistants should be trained in the care and
cleaning of this equipment, and the cart should be
checked with the same regularity as a code cart to
verify availability of all the equipment and supplies
necessary to respond to an airway emergency. Re-
placement equipment should be in place when
equipment is undergoing routine maintenance or
is being repaired.
There are a number of different tools to assess for
risk of a difficult intubation,74-80 and no one tool is
fail-safe.72 The team should review the evidence
supporting available risk assessment tools and select
one or more appropriate tools for the health care
facility. Surgical team briefings should include
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airway risks identified and the plan for management
of any airway issue. There should be a standardized
plan in place to designate a rapid response team. The
contact mechanism should be the same, no matter
who is the responder (eg, same paging mechanism).
After a difficult airway management event, infor-
mation about the event should be communicated
with the patient, primary care provider, and other
health care providers. A Difficult Airway Alert
Form81 can be used or modified to assist with this
communication (Figure 2).
Lastly, the interdisciplinary perioperative team
should regularly practice responding to and man-
aging airway emergencies, as well as assessing
team member competency. It is critical that this
education and training be team-based. Seconds
matter in an airway emergency, and simulation
facilitates the ability of team members to rapidly
respond to emergencies when they arise. A pro-
spective controlled study using simulation showed
that adherence to a difficult airway guideline by
anesthesiologists was sustained for six to eight
months for the “can’t intubate, can’t ventilate”
scenario but only six to eight weeks for the more
complex “can’t intubate” scenario. This training
should occur at least every six months.82
SUMMARY
We have reviewed the top 10 patient safety issues
identified through a survey of perioperative nurses,
described the evidence supporting the overall seri-
ousness of these issues, and identified contribut-
ing factors. Based on this evidence, we have made
recommendations for additional steps that periop-
erative nurses can take to enhance patient safety.
Three of these issues have been described as “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
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June 2013 Vol 97 No 6 STEELMANdGRALING

Figure 2. The Pennsylvania Patient Safety Authority Difficult Airway Alert Form is a communication tool used to
alert patient care providers that a patient has a potentially difficult airway. It can be modified for the individual
practice setting. Reprinted with permission from the Pennsylvania Patient Safety Authority.

694 j AORN Journal

TOP 10 PATIENT SAFETY ISSUES
available to perioperative nurses. Some of these
focus on the value of briefing before and debriefing
after surgery. Others emphasize the value of pro-
spective risk assessment. Regardless of the issue,
perioperative nurses should collaborate with other
disciplines to review national data to identify safety
issues. We should also analyze internal data about
adverse events and near misses and design and im-
plement a corrective action plan based on lessons
learned. Our quest for improving the quality and
safety of perioperative patient care is unending, and
it is a professional responsibility that provides us
with the direction needed to continuously improve
our health care system.
SUPPLEMENTARY DATA
The supplementary figure associated with this
article can be found in the online version at http://
dx.doi.org/10.1016/j.aorn.2013.04.012.
Acknowledgments: The authors thank Deborah
Spratt, MPA, BSN, RN, CNOR, NEA-BC, CRCST,
CHL, manager of the sterile processing department
at Canandaigua Veterans Affairs Medical Center,
Canandaigua, New York, for reviewing the content
on failures in reprocessing instruments and 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 difficult
intubation or airway emergencies.
Editor’s 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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UniqueTM: a study of 15,795 patients. Anesthesiology.

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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 affiliation that could
be perceived as posing a potential conflict 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 affiliation that could
be perceived as posing a potential conflict of
interest in the publication of this article.

698 j AORN Journal

EXAMINATION
3.9
CONTINUING EDUCATION PROGRAM

Top 10 Patient Safety Issues: www.aorn.org/CE

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 identified in an AORN member survey.
2. Identify methods to mitigate the risks of injury posed by the identified 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 6. taking intraoperative radiographs for all

abdominal procedures.
1. The number one patient safety issue identified in a. 1, 2, and 3 b. 4, 5, and 6
a survey of perioperative nurses is preventing c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
a. perioperative hypothermia.
b. wrong site/procedure/patient surgery.
3. Opportunities to prevent medication errors
c. retained surgical items.
include
d. medication errors.
1. minimizing verbal orders.
2. Recommendations for preventing retained 2. implementing standard order sets.
surgical items include
3. implementing briefings with the surgeon
1. minimizing distractions and multitasking
before each procedure.
while managing counted items.
2. alerting the team that the count will be 4. using surgeon preference cards to identify
starting. doses.
3. prioritizing other urgent tasks before starting 5. labeling medications and solutions that are
the count. removed from their original containers.
4. actively enforcing the facility’s procedures 6. communicating with the surgeon when
for managing counted items. handing off medications.
5. evaluating adjunct technology to support the a. 1, 3, and 5 b. 2, 4, and 6
surgical count. c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

AORN, Inc, 2013 June 2013 Vol 97 No 6
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June 2013 Vol 97 No 6 CE EXAMINATION

4. Reprocessing instruments in the OR is high risk 4. performing a fire risk assessment before
because making the initial incision.
a. the decontamination equipment in the OR is 5. providing multidisciplinary training and
not adequate to properly reprocess instruments. drills.
b. OR personnel may try to circumvent the rigor a. 4 and 5 b. 1, 2, and 3
required for effective reprocessing. c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
c. OR personnel are not trained to properly
reprocess instruments. 8. Perioperative hypothermia is an important issue
d. sterilizers in the OR have a higher failure rate. for all anesthetized surgical patients because it
1. increases the risk of postoperative surgical
5. To safely transfer and position patients in site infection.
a manner that prevents shearing, personnel should 2. causes coagulopathy and the need for
use a mechanical lifting device for a supine-to- transfusion.
supine transfer of a patient weighing more than 3. extends the duration of neuromuscular
a. 157 lb. b. 175 lb. blocking agents and delays recovery.
c. 187 lb. d. 195 lb. 4. triples the risk of a morbid cardiac event
occurring.
6. To prevent errors with specimen management, 5. increases the risk of renal failure and need for
perioperative personnel should dialysis.
1. avoid multitasking during specimen a. 4 and 5 b. 1, 2, and 3
management. c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
2. ensure that two people verify the label and
9. Important safety measures to implement during
contents before transferring the specimen out
phacoemulsification include
of the OR.
1. ensuring that an appropriately sized disper-
3. discuss anticipated specimens in the preop-
sive electrode is placed on all patients.
erative briefing with the surgeon.
2. ensuring that an extra bottle of fluid is readily
4. label specimens with two unique identifiers.
accessible in the OR for immediate use.
5. perform a debriefing with the surgeon at the
3. providing supplemental lighting in the OR to
end of the procedure to review specimen
assist with visual inspection of fluid levels
identification and the fixative used.
and operating equipment.
6. verify the accuracy of information on each 4. using an irrigation fluid chamber monitor
patient label.
with an alarm that alerts personnel to low
a. 1, 3, and 5 b. 2, 4, and 6
fluid levels.
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
a. 1 and 3 b. 2 and 4
c. 2, 3, and 4 d. 1, 2, 3, and 4
7. Recommendations that could be part of a fire
safety program include 10. ________________ should be the primary
1. allowing ample time for flammable prep decision makers for what equipment and supplies
agents to dry. are purchased and stocked in the difficult airway
2. communicating about the use of an open management cart.
source of oxygen or flammable prep agent a. Anesthesia professionals
before making the incision. b. OR nurses
3. holstering the electrosurgery pencil when it is c. Postanesthesia care unit nurses
not in use. d. Surgeons

700 j AORN Journal

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
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 identified in an
AORN member survey.
Low 1. 2. 3. 4. 5. High
2. Identify methods to mitigate the risks of injury posed
by the identified 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.)

AORN, Inc, 2013
3.9
www.aorn.org/CE
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: _________________________________
June 2013 Vol 97 No 6
AORN Journal j 701