CONTINUING EDUCATION

Implementing AORN
Recommended Practices
for Laser Safety
DONNA CASTELLUCCIO, MSN, RN, CNOR 2.6
www.aorn.org/CE

Continuing Education Contact Hours Approvals

indicates that continuing education contact hours are avail-
able for this activity. Earn the contact hours by reading this arti-
cle, reviewing the purpose/goal and objectives, and completing
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The contact hours for this article expire May 31, 2015.
Purpose/Goal
To educate perioperative nurses about how to implement the
AORN “Recommended practices for laser safety in perioper-
ative practice settings” in inpatient and ambulatory settings.
Objectives
1. Identify potential risks involved with the use of medical
lasers.
2. Discuss AORN’s practice recommendations for the use
and care of laser equipment.
3. Discuss AORN’s practice recommendations for providing
a safe environment for patients and health care workers.
4. Describe methods for implementing AORN’s practice rec-
ommendations for laser safety.
Accreditation
AORN is accredited as a provider of continuing nursing edu-
cation by the American Nurses Credentialing Center’s Com-
mission on Accreditation.
This program meets criteria for CNOR and CRNFA
recertification, as well as other continuing education
requirements.
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 activ-
ity for relicensure.
Conflict of Interest Disclosures
Ms Castelluccio has no declared affiliation that could be per-
ceived as posing a potential conflict of interest in the publi-
cation of this article.
The behavioral objectives for this program were created by
Kimberly Retzlaff, editor/team lead, with consultation from
Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan
Bakewell, MS, RN-BC, director, Perioperative Education.
Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared
affiliations that could be perceived as posing potential con-
flicts 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 edu-
cation for registered nurses. This recognition does not im-
ply that AORN or the American Nurses Credentialing
Center approves or endorses products mentioned in the
activity.

doi: 10.1016/j.aorn.2012.03.001
612 AORN Journal ● May 2012 Vol 95 No 5 © AORN, Inc., 2012
RECOMMENDED PRACTICES
Implementing AORN
Recommended Practices
for Laser Safety
2.6
DONNA CASTELLUCCIO, MSN, RN, CNOR

www.aorn.org/CE

ABSTRACT
Lasers used in the OR pose many risks to both patients and personnel. AORN’s
“Recommended practices for laser safety in perioperative practice settings” identifies
the potential hazards associated with laser use, such as eye damage and fire- and
smoke-related injuries. The practice recommendations are intended to be used as a
guide for establishing best practices in the workplace and to give perioperative
nurses strategies for implementing the recommended safety measures. A laser safety
program should include measures to control access to laser use areas; protect staff
members and patients from exposure to the laser beam; provide staff members and
patients with the appropriate safety eyewear for use in the laser use area; and protect
staff members and patients from surgical smoke, electrical, and fire hazards. Mea-
sures such as using a safety checklist or creating a laser cart can help perioperative
nurses successfully incorporate the practice recommendations. Patient scenarios are
included as examples of how to use the document in real-life situations. AORN J 95
(May 2012) 613-624. © AORN, Inc., 2012. 10.1016/j.aorn.2012.03.001

Key words: AORN recommended practices, laser safety, fire safety, smoke
plume, smoke evacuation.

L
aser technology has been evolving for
more than 40 years. AORN mentioned
laser safety in 1985 in the recommended
practices (RP) document about radiation safety,1
and AORN’s recommended practices for laser
safety were originally published in November
1989.2 The RP document has been revised four
times to incorporate new information that has be-
come available over the years.3 The hazards of
smoke plume were noted in the original 1989 ver-
sion. In 1993, the recommendations stated that a
laser team should be available for each procedure
in which a laser would be used.4 The role of the
laser safety officer (LSO) appeared for the first
time in 1998.5 The 2004 RP document discussed
establishing a laser safety program per the Ameri-
can National Standards Institute (ANSI) recom-
mendations.6 The most recent laser safety RP was

© AORN, Inc., 2012 May 2012 Vol 95 No 5 ● AORN Journal 613

May 2012 Vol 95 No 5
first published electronically in November 2010 in
the AORN Perioperative Standards and Recom-
mended Practices.3
The purpose of the laser safety RP document is
to “provide guidance to perioperative personnel in
the use and care of laser equipment and to assist
practitioners in providing a safe environment for
patients and health care workers.”3(p125) These
recommendations apply whether laser equipment
is owned, leased, or borrowed and in any health
care setting in which medical laser equipment is
used. The foundation for all laser safety programs
should be the ANSI standards for class 3 and
class 4 laser devices that are used in health care
facilities, and these standards are the basis for
AORN’s recommendations. There are 11 recom-
mendations in the current version of the laser
safety RP document.
WHAT’S NEW?
The newest RP document contains a number of
significant changes. The 2010 iteration expands
on what a laser safety program should entail and
further defines responsibilities of the LSO. A la-
ser safety specialist (LSS), also called a laser re-
source nurse, appears in the document as a new
role with a unique set of responsibilities. Another
new recommendation is that a designated laser
assistant be assigned to every procedure in
which a laser is used, and this person should
have no competing responsibilities that require
leaving the laser unattended during active use.
The hazards of surgical smoke and fire are de-
tailed more extensively in this updated docu-
ment, reflecting current evidence.
RATIONALE
Lasers are a valuable tool in the OR; however,
there are hazards associated with this technol-
ogy. Taking proper safety precautions will sig-
nificantly reduce the risks to both patients and
perioperative personnel.
“Laser” is an acronym for Light Amplification
by the Stimulated Emission of Radiation. Light
614 AORN Journal
CASTELLUCCIO
refers to all the energy on the electromagnetic
radiation spectrum, whether it is visible or invisi-
ble. Lasers produce light when energy is added to
a medium and causes the release of energy in the
form of a narrow beam of high-energy light. The
stimulated energy can be a flash-lamp, another
laser, or a liquid. Laser energy can be infrared,
ultraviolet, or visible. Different wavelengths have
different effects on tissue, so the wavelength of
the laser determines the appropriate application
and safety measures.
Light can have four interactions with tissue:
reflected, scattered, transmitted, and absorbed.
With reflected and scattered interactions, there is
the danger of light energy being uncontrolled.
The reasoning is complicated, but a reflected or
scattered beam can hit something reflective and
bounce off and go anywhere, which is danger-
ous. Transmission and absorption are the de-
sired qualities for a laser; to have an effect on
tissue, laser light must be absorbed. Light can
be transmitted or pass through some tissue with
no effect, while other tissue will absorb the en-
ergy.7 The thermal effect of the laser is cutting,
coagulating, and vaporizing.
Lasers today are being used in all types of
surgeries (eg, ophthalmology, urology, orthope-
dics, gynecology) and can be found in hospi-
tals, ambulatory surgery centers, and office-
based practices. The benefit of using medical
lasers is that they seal small blood vessels and
decrease edema and pain.
Perioperative nurses must institute control mea-
sures to minimize laser hazards:
 Laser beams are a source of intense light7-9
and can cause injury to the cornea and retina,
either from direct viewing or scattered beams.
Eye damage may be temporary but can also
cause blindness.9
 Laser radiation can cause irreversible damage
to the skin. Lasers are thermal in nature and
can cause burns if there is sufficient intensity
and duration.8
RP IMPLEMENTATION GUIDE: LASER SAFETY
 Concerns about surgical smoke are mounting.
The by-product of the thermal destruction of
tissue contains “toxic gases and vapors such
as benzene, hydrogen cyanide, and formal-
dehyde, bioaerosols, dead and live cellular
material (including blood fragments), and
viruses.”10 Surgical smoke should be removed
by use of a smoke evacuation system.3,9,11
 Lasers are a potential ignition and fire source
because of the intense heat produced.12
When aware of the risks, perioperative nurses
can take the proper precautions to maintain a
safe environment.
Several organizations provide guidelines that
are recognized as accepted standards for laser
safety. These agencies, including the Occupational
Safety and Health Administration (OSHA), ANSI,
and AORN, promote the proper use, precautions,
and maintenance of lasers.
The Joint Commission, as part of a survey,
may investigate a facility’s laser program to en-
sure adherence to the ANSI Z136.3 standards.11
Figure 1. Laser-specific information should be posted on the signs at every door where a laser is being used.
www.aornjournal.org
For example, ANSI recommends the use of high-
filtration masks during laser use and posting of
laser-specific information on signs (Figure 1) at
every door of the room in which a laser is being
used. Although ANSI is not a regulatory agency,
its standards are considered to be the gold stan-
dard. The Joint Commission will look at laser
policy, training, and credentialing of surgeons.13
Requirements from OSHA include that mea-
sures must be taken to provide for a safe environ-
ment for staff members, which includes the re-
moval of surgical smoke. The AORN Surgical
Smoke Evacuation Tool Kit14 offers tools and
resources to educate perioperative nurses about
the hazards of surgical smoke and to help periop-
erative personnel research, plan, design, and im-
plement a smoke evacuation program. The ECRI
Institute also publishes a self-assessment question-
naire on laser safety to help identify and manage
risks.15 This questionnaire will help perioperative
staff members evaluate their program to ensure
that proper measures are in place.
AORN Journal 615
May 2012 Vol 95 No 5 CASTELLUCCIO

DISCUSSION  ensuring an LSS is available for each area of

It is important to establish safety guidelines in laser use when there are multiple sites in a
any facility in which lasers are used. The AORN health care organization.3
recommended practices for laser safety include
The committee should review recommendations
establishing a laser safety program and a multi-
from AORN and ANSI, develop a policy, and
disciplinary laser safety committee and con-
make sure all the safety components are identi-
trolling measures that are necessary to ensure
fied. Establishing a program and then maintaining
patient and staff member safety. Specifically, a
it takes time, effort, and dedication; however, it is
laser safety program should include safety mea-
a crucial component for safe laser use.
sures to control access to laser use areas; pro-
In a facility that is just starting a laser safety
tect staff members and patients from uninten-
program, it is essential to have administrative
tional exposure to the laser beam; provide staff
support to help ensure the success of the program.
members and patients with the appropriate
Perioperative nurses may start by meeting with all
safety eyewear for use in the laser use area;
the stakeholders, such as perioperative manag-
and protect staff members and patients against
ers, laser accredited surgeons, and risk manage-
surgical smoke, electrical, and fire hazards.
ment personnel, who will then become the laser
program safety committee. Having a laser-
Recommendation I
credentialed physician champion on the com-
“A laser safety program should be established
mittee who embraces the project and is influen-
for all owned, leased, or borrowed laser equip-
tial in getting others to comply with laser
ment in any location where lasers are used in
safety regulations would be ideal. Then, the
the health care organization.”3(p125) A multidis-
health care organization should select the LSO.
ciplinary laser safety committee is an essential
The LSO should be qualified through education
element of this program for any facility, hospi-
and experience. If no one at the facility has
tal, or ambulatory surgery center in which la-
experience with a laser safety program, then a
sers are used. The committee can be part of the
person with an interest should review the litera-
larger risk management and safety committee or
ture, become familiar with protocols, and com-
quality improvement program, but ideally, the
plete a laser certification course.16,17
committee should be in place before a laser
An interested perioperative nurse may start by
program is implemented.
approaching his or her manager with the RPs in
The laser safety committee needs to establish
hand to discuss various components of a laser
administrative controls (ie, methods to regulate
safety program and what needs to be done to cre-
work practice) that assist staff members in mini-
ate or update an existing program. If there is no
mizing risks. The RP document defines who
existing committee, this meeting would be the
should be on the committee and their responsibili-
place to begin creating a committee and the pro-
ties, including
gram. An interested perioperative nurse should let
 designating an LSO to monitor and oversee the manager know that he or she is familiar with
the control of laser safety hazards, the AORN recommended practices for laser safety
 developing and enforcing policies and and offer his or her assistance in starting or im-
procedures, proving a laser safety program. This person
 verifying physician credentialing, should educate himself or herself by doing some
 educating personnel, reading on the subject. An educator could help
 identifying laser hazards, and with collecting data, but anyone with an interest

616 AORN Journal

RP IMPLEMENTATION GUIDE: LASER SAFETY
could be of assistance. For an ambulatory surgery
center or other facility that contracts a laser ser-
vice, education, resources, and references may be
provided. Industry representatives or guest speak-
ers also may be helpful for educating staff mem-
bers. The laser representative may be able to
help set up a program, answer questions, or
refer staff members to other resources. Staff
members at other institutions or peers on AORN’s
ORNurseLink also may have valuable input.
If a laser safety program is already in place, an
interested perioperative nurse should identify the
barriers that might be encountered in trying to
implement new practice recommendations. An
interested perioperative nurse or the LSO should
listen to staff member concerns. If staff members
are asked to provide input, they will be more in-
volved in the project and more likely to help with
implementation. If staff members do not adhere to
the recommendations, an interested periopera-
tive nurse or the LSO should investigate why.
After the challenges are identified, action can
be taken. For example, an interested periopera-
tive nurse or the LSO could start a laser safety
awareness campaign and engage everyone
(eg, nurses, surgeons, surgical technologists)
who has knowledge of lasers to get involved.
An interested perioperative nurse or the LSO
should enlist the help of staff members who
regularly participate in laser procedures or
who have an interest and can motivate others
to follow policy. Another option is to make a
poster on the effects of surgical smoke, for
example, to get staff members’ attention; mak-
ing staff members aware of potential hazards
helps to garner their support in following laser
safety policies.
In a facility in which a program is already in
place, the focus should be on making sure all the
elements of the RP document are in place. If a
committee and an LSO are already established,
forming the role of an LSS may be the next step.
This resource person works with the LSO, is
present in the laser use area, and acts as liaison
www.aornjournal.org
between clinicians and the LSO. The LSS trou-
bleshoots equipment problems and acts as a re-
source to other staff members. Further responsi-
bilities can be found in the current RP document.
Because of the risks associated with laser use, a
laser assistant should be assigned to every proce-
dure in which a laser is used and should have no
competing duties while the laser is activated. Des-
ignating a laser assistant for every laser procedure
may prove difficult in a facility that has staffing
issues, but this role is important for minimizing
laser hazards.
The focus of any new or existing program for
laser safety will be education. It is vital that ev-
eryone who is involved with lasers be educated
on the use and care of laser equipment and on
maintaining an environment of safety. The LSO
or perioperative educators should initiate this edu-
cation. There are many resources available, and
Laser Safety in the Perioperative Setting18 from
the AORN Video Library is a good starting point.
The LSO at my facility is certified in laser use
from the Laser Institute of America. She re-
views our policy annually, makes sure we have
the proper equipment and that it is in working
order, audits problems, and takes a lead in edu-
cating staff members. We conduct a mandatory,
annual laser safety inservice program for all
perioperative staff members and then about a
dozen nurses undergo hands-on training as su-
per-users/laser assistants. All new staff mem-
bers, as part of their orientation, receive laser
safety education.
Recommendations II, III, and IV
Three practice recommendations address the con-
trol measures necessary for patient and staff
member safety, including ensuring that personnel
know where lasers are being used and controlling
access to laser use areas, protecting patients and
personnel from unintentional laser beam exposure,
and ensuring that all people in laser use areas
wear the appropriate safety eyewear.3 These
standards must be followed to ensure a safe
AORN Journal 617
May 2012 Vol 95 No 5
environment. Perioperative nurses should read the
full recommendations, create a list of what needs
to be done at their institutions to comply with the
standards, and then implement solutions. If ser-
vices are contracted, these safety controls may be
provided by the vendor.
The nominal hazard zone—the space in which
the level of direct, reflected, or scattered radiation
used during normal laser operation exceeds the ap-
plicable maximum permissible exposure—should be
clearly marked with recognizable warning
signs. The laser vendor should be able to sup-
ply signs. Each sign must be specific to the la-
ser in use and state the eye protection that staff
members need to wear if they enter the room.
Protecting staff members and patients from unin-
tentional laser beam exposure is important because
lasers can cause eye and skin damage.11 Practices to
prevent unintentional exposure include
 placing the laser in standby mode when it is
not in use11,19-21;
 placing the foot switch near the operator; and
 using anodized, dull, nonreflective, or matte-
finished instruments near the laser site.11,19,20,22
Eyewear specific to each laser, per manufac-
turer recommendation, is required in the nominal
hazard zone.3,8,9 Glasses must be labeled with
appropriate optical density and wavelength.11,20,23
The patient’s eye safety also must be considered:
glasses if the patient is awake, wet eye pads if he
CHECK APPROPRIATE SAFETY PRECAUTIONS TAKEN IN ROOM
LASER SIGNS POSTED
LASER GLASSES AT ALL DOORS
SMOKE EVACUATOR SET UP
LASER MASKS ON ALL STAFF
FIBER TIP COVERED W/ITH WET 4x4 IN STANDBY
60 mL SYRINGE WITH H2O or NaCl ON MAYO FOR THROAT CASES
TRACH TRAY WITH TRACHEOTOMY TUBES FOR ALL THROAT CASES IN
THE ROOM
BASIN OF WATER ON FIELD
Figure 2. Using a checklist of precautions that is part of the documentation serves as a reminder of laser
safety precautions.
618 AORN Journal
CASTELLUCCIO
or she is asleep, or metal corneal shields if the
treatment area is around the patient’s eyes.
Laser safety has a lot of components, so in my
facility’s OR, the LSO, managers, and I made a
checklist of precautions that is part of our docu-
mentation (Figure 2). The laser resource nurse
assigned to the room must complete this checklist
before laser use; hang signs on each door; and
ensure the availability of laser-safe instruments,
water, and a fire extinguisher. To help imple-
ment laser safety recommendations, perioperative
nurses should use the AORN recommendations to
create their own checklists for better compliance.
Lasers: The Perioperative Challenge, 3rd edition,
also has examples of checklists and policies.7
After the list is made, an interested periopera-
tive nurse or the LSO should make sure all the
necessary elements are available for use, such as
laser-safe instruments, proper eyewear, and a
smoke evacuation system. One author found the
number-one barrier to smoke evacuation was lack
of equipment.24 If the necessary safety items are
not available, acquiring them is essential. If pur-
chasing these safety items is a problem, then the
LSO or a nurse advocate should approach the
appropriate managers and present a well-informed
case for their acquisition. Or, perhaps the program
needs to be suspended until the appropriate de-
vices are available. If there is any question or
concern that a nurse feels is not being addressed,
WET TOWELS FOR DRAPING
NON-FLAMMABLE PREP
EBONIZED INSTRUMENTS USED
HANDPIECE COVERED WITH WET TOWEL IN
STANDBY
RECTAL PACK – WET 4x4
LASER SAFE ENDOTRACHEAL TUBE
OTHER
FIRE EXTINGUISHER IN ROOM
RP IMPLEMENTATION GUIDE: LASER SAFETY
he or she has an obligation to report up the chain
of command as necessary in a timely fashion for
the safety of patients and personnel. This may
include reporting to the committee or risk man-
ager or via a facility hotline if one is available
and documenting these reports via an online sys-
tem or an internal quality reporting system. It
may be necessary to get OSHA involved if there
is a continuing problem. If an institution is non-
compliant with the laser safety protocols and at-
tempts have been made to get the protocols insti-
tuted, then whistle blowing may be in order. This
action should only be taken after all attempts at
resolving the issue through the chain of command
have been exhausted.
To ensure proper safety measures are imple-
mented, perioperative team members can review
laser safety precautions in a huddle before the
patient enters the room or at the time out. At
my facility, the LSO set up a laser cart so
most of what we need—such as glasses, signs,
attachments, masks, tongue blade, and eye
pads—is in one place. We also have a resource
book with each laser that states
 whether it needs to be tested and, if so, how;
 what equipment must be in the room;
Figure 3. A page from a laser resource book might include details such as what type of eyewear is necessary
during laser use and whether windows need to be covered.
www.aornjournal.org
 whether windows need to be covered; and
 the correct eyewear that should be used (Figure 3).
The resource book also contains pictures of various
laser components and lists directions for how to
assemble them. This information helps staff mem-
bers comply with our facility laser guidelines.
No matter the type of facility—whether hospi-
tal or ambulatory surgery center— or whether la-
ser equipment is owned or rented, the role of the
circulating nurse will be the same. The RN circu-
lator must be aware of and enforce all laser safety
precautions, such as correct signage being posted
on the doors and the availability of the correct
eyewear and a fire extinguisher in the room. A
laser assistant should be at the laser console dur-
ing use to oversee the safe use of the laser. Estab-
lishing an LSS in the area of laser use provides
an opportunity for that person to model proper
precautions and to reinforce them with the other
staff members in the room. Every laser procedure
then becomes a potential teachable moment.
Recommendation V
“Potential hazards associated with surgical
smoke generated in the laser practice setting
should be identified and safe practices
AORN Journal 619
May 2012 Vol 95 No 5
established.”3(p130) The National Institute for
Occupational Safety and Health (NIOSH),
OSHA, Laser Institute of America, ANSI,
AORN, and The Joint Commission recommend
that surgical smoke be filtered and evacuated
through the use of room ventilation, smoke
evacuators, and room (wall) suction systems.25
The evidence shows that surgical smoke con-
tains toxic gases and vapors like cyanide and
formaldehyde, as well as bacterial and viral
contaminants.10,11,26,27
In addition to a smoke evacuation system,
staff members should wear high-filtration masks
to filter particulate matter as a second line of
defense.9 If compliance with wearing masks
and using smoke evacuators is a problem, an
interested perioperative nurse or the LSO could
have staff members read articles on the hazards
of surgical smoke from NIOSH, AORN, and
the ECRI Institute. The evidence shows “peri-
operative nurses experience respiratory symp-
toms at a higher rate—sometimes twice the
rate—as others in the United States.”24(p60) In
one study, nurses experienced more sinus infec-
tions and other problems and reported higher
rates of allergies, bronchitis, and asthma than
the general public.24
If this evidence does not improve compliance,
an interested perioperative nurse could make staff
members aware of the surgeon who acquired pap-
illomavirus while treating patients with anogenital
condylomas28 or that 1 g of lasered tissue is equal
to smoking three cigarettes in 15 minutes.14 Put-
ting this information on a poster or in a newslet-
ter or discussing it at a staff meeting may in-
crease compliance.
Recommendations VI and VII
Two recommendations are related to protecting
staff members from hazards associated with
laser use, specifically electrical and flammable
hazards. During laser use, all basic electrical
safety precautions must be followed, such as
not putting liquids on the console; not using
620 AORN Journal
CASTELLUCCIO
extension cords; and checking wires for fray-
ing, cracks, or breaks. Electrical problems are
only one of many fire hazards, however. All
three components of the fire triangle (ie, oxidiz-
ers, fuel, ignition sources) are present in the
OR, which makes laser use a high risk for sur-
gical fires.29,30 Because of these factors, fire is
the greatest risk of using lasers, and safety
precautions must be followed. Examples of fire
safety precautions during laser use include not
activating the laser beam in the presence of
flammable gases and keeping sponges and
drapes near the surgical site moist.
Personnel also should be prepared to immedi-
ately extinguish flames should they occur.12 Sim-
ulation exercises that include putting out mock
fires and evacuating rooms should be an annual
event so everyone is prepared. If fire safety ed-
ucation is not a mandatory, annual occurrence
at an institution, an interested perioperative
nurse should make it happen by taking his or
her concerns to perioperative leaders or the
LSO and requesting help with compliance. The
AORN Fire Safety Tool Kit31 is a comprehen-
sive resource that may be used to raise periop-
erative staff member awareness of the inherent
realities of surgical fires and provide proactive
tools to promote fire prevention, plan effective
response strategies, and develop department-
specific, evidence-based policies and protocols
to protect patients and staff members.
As with the previously discussed recommen-
dations, anyone who works during laser proce-
dures should follow all the steps that are out-
lined in the RP document. If staff members are
not following policy, an LSO, an LSS, a peri-
operative leader, or a concerned perioperative
staff member should determine why and then
determine what needs to be done. At my facil-
ity, the LSO and I mounted the fire extin-
guisher and smoke evacuator on the laser cart
so they are always where we need them, mak-
ing compliance easy.
RP IMPLEMENTATION GUIDE: LASER SAFETY www.aornjournal.org

The Final Four Perioperative Standards and Recommended Prac-

The final four recommendations in each AORN
RP document discuss education/competency, doc-
umentation, policies and procedures, and quality
assurance/performance improvement. These four
topics are integral to the implementation of
AORN practice recommendations. Personnel
should receive initial and ongoing education and
competency validation as applicable to their roles.
Implementing new and updated recommended
practices affords an excellent opportunity to cre-
ate or update competency materials and validation
tools. AORN’s perioperative competencies team
has developed the AORN Perioperative Job De-
scriptions and Competency Evaluation Tools32 to
assist perioperative personnel in developing com-
petency evaluation tools and position descriptions.
Documentation of nursing care should include
patient assessment, plan of care, nursing diagno-
sis, and identification of desired outcomes and
interventions, as well as an evaluation of the pa-
tient’s response to care. Implementing new or
updated recommended practices may warrant a
review or revision of the relevant documentation
being used in the facility.
Policies and procedures should be developed,
reviewed periodically, revised as necessary, and
readily available in the
practice setting. New or
updated recommended AORN Resources
practices may present an
opportunity for collabora-  Fire Safety Tool Kit. http://www.aorn.org/FireSafety/.
tices. Regular quality improvement projects are
necessary to improve patient safety and to ensure
safe, quality care. For details on the final four
practice recommendations that are specific to the
RP document discussed in this article, please refer
to the full text of the RP document.
AMBULATORY PATIENT SCENARIO
A 26-year-old man with condylomata of the geni-
tals is scheduled for a laser vaporization proce-
dure under general anesthesia. The procedure is
expected to take less than 30 minutes. He has a
history of asthma but is otherwise healthy. Nurse
C is the laser assistant assigned to the procedure.
Nurse C uses the laser safety checklist to prepare
the room. She hangs the CO2 laser signs on both
doors into the room as well as the appropriate
glasses. She tests the laser handpiece, has glasses
for everyone in the room, and ensures sterile wa-
ter and a fire extinguisher are available. She pro-
cures the smoke evacuator and gives the scrub
person the proper tubing with the wand attach-
ment. Nurse C reminds the scrub person to use
wet towels and sponges and to keep the wand as
close to the site of surgery as possible to evacuate
the smoke.

tive efforts with nurses and  Smoke Evacuation Tool Kit. http://www.aorn.org/Clinical_

personnel from other de- Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/

partments in the facility to Surgical_Smoke_Evacuation_Tool_Kit.aspx.
develop organization-wide  Laser Safety specialty module. http://www.aorn.org/Education/
policies and procedures that Specialty_Education/Laser_Safety/Laser_Safety.aspx.
support the recommended  Laser Safety in the Perioperative Setting [DVD] (Ciné-Med,

practices. The AORN Pol- 2011). http://cine-med.com/index.php?nav⫽aorn.

icy & Procedure Templates,
2nd edition,33 provides a
collection of 15 sample poli-
cies and customizable tem-
plates based on AORN’s
 Ball KA. Lasers—The Perioperative Challenge. 3rd ed. Den-
ver, CO: AORN, Inc; 2004. http://www.aornbookstore.org//
product/product.asp?sku⫽MAN186.
Web site access verified January 23, 2012.

AORN Journal 621

May 2012 Vol 95 No 5
The circulating nurse checks that everything is
ready and brings the patient into the room. Every-
one has laser masks on. The physician tells Nurse
C the settings for the laser and that he is ready to
go; she turns on the laser and the smoke evacua-
tor. The smoke evacuator does not turn on. Nurse
C informs the surgeon that he needs to stop while
she troubleshoots the smoke evacuator, and she
puts the laser in standby mode. The surgeon
wants to proceed, saying, “It will only take five
minutes, it will take longer to get another smoke
evacuator.” The surgeon demands that the laser
be turned on. What should Nurse C do?
As the person responsible for safe laser use in
the room, Nurse C should immediately call for a
new smoke evacuator. Then she should explain to
the surgeon, as she troubleshoots, the hazards of
surgical smoke. Nurse C should be able to cite
patient and staff member safety, explaining that
the smoke could irritate the respiratory system
and may exacerbate the patient’s asthma. By
knowing the standards and the rationale, Nurse C
can be confident and assertive, and she can re-
main calm under pressure and thus support best
practice. Explaining the rationale and not arguing
make for a smooth, safe procedure.
HOSPITAL PATIENT SCENARIO
Mr G, who is 68 years old, is undergoing a mi-
crolaryngoscopy for a vocal cord lesion. Nurse
A is the laser assistant for the procedure. She
Resources for Implementation
 AORN Nurse Consult Line. (800) 755-2676 or (303) 755-
6300, option 3.
 ORNurseLink. http://www.aorn.org/ORNurseLink.
 Perioperative Job Descriptions and Competency Evaluation
Tools [CD-ROM]. http://www.aorn.org/Books_and_
Publications/AORN_Publications/Perioperative_Job_
Descriptions_and_Competency_Evaluations_Tools.aspx.
Web site access verified January 23, 2012.
622 AORN Journal
CASTELLUCCIO
checks the laser beam for accuracy with the
microscope attachment after taking all general
safety and fire prevention precautions. She
makes sure the anesthesia professional has a
laser-safe endotracheal (ET) tube; notes the
scrub person has a 60-mL syringe of saline;
and sees that the circulating nurse has the
emergency instruments, tracheotomy tray, and
bronchoscope outside the door according to fa-
cility policy. A basin of sterile water, fire extin-
guisher, and laser-safe instruments are all as-
sembled per policy. The surgeon places a wet
cottonoid in the patient’s throat. The surgeon
begins the procedure. After about three min-
utes, a fire erupts and Nurse A yells, “Fire!”
What are the team members’ responsibilities at
this point?
The actions of the various team members may
be happening simultaneously:
Surgeon
 Stop lasering.
 Perform a bronchoscopy to assess the dam-
age after fire is extinguished.
 Anesthesia professional
 Immediately turn off the oxygen.
 Remove the ET tube while disconnecting
the ET tube from the breathing circuit.
 Check to make sure the ET tube is intact.
 Re-establish the airway using air, switch-
ing to oxygen when it has been deter-
mined that there is no burning in the
airway.
 Perform a bronchos-
copy to assess the
damage after the fire
is extinguished if it is
not performed by the
surgeon.
 Scrub person
 Pour saline into the
airway.
 Remove burning or
flammable drapes or
other materials.
RP IMPLEMENTATION GUIDE: LASER SAFETY
 Circulating nurse
 Call for help according to established facil-
ity policy.
 Assist other team members as needed.
 Nurse A (laser assistant)
 Put the laser in standby mode.
Because of the team’s quick response, the patient
did not sustain any injuries. The patient was
reintubated and the surgery was completed with-
out incident.
Requiring all perioperative team members to
attend regular fire safety inservice programs will
help ensure they will be able to react instinctively
in the event of a fire. Having all the precautions
in place and educating staff members can avert a
potential catastrophe.
CONCLUSION
Lasers are a valuable tool in surgery but also
present significant risk. The AORN “Recom-
mended practices for laser safety in perioperative
practice settings” is a comprehensive guideline for
achieving the optimal level of practice. The RP
document gives perioperative nurses all the key
elements to ensure industry standards are fol-
lowed. The RP document should be the basis for
a facility’s policy and procedures wherever lasers
are used. There are many safety precautions that
must be taken, but these precautions, defined in
the RP document, are at the heart of laser safety
and should be a part of every laser program.
For the best outcomes, a solid program should
be in place. At a minimum, the scrub person and
circulating nurse should know their roles in laser
use. Other staff members may need the guidance
of an LSO to make them aware of the recom-
mended practices.
References
1. Recommended practices: radiation safety in the operat-
ing room (including lasers). AORN J. 1985;42(6):920-
930.
2. Recommended practices for laser safety in the practice
setting. In: AORN Standards and Recommended Prac-
tices for Perioperative Nurses. Denver, CO: The Asso-
ciation of Operating Room Nurses, Inc; 1990:111:7-1-
111:7-5.
www.aornjournal.org
3. Recommended practices for laser safety in perioperative
practice settings. In: Perioperative Standards and Rec-
ommended Practices. Denver, CO: AORN, Inc; 2012:
125-142.
4. Recommended practices for laser safety in the practice
setting. In: AORN Standards and Recommended Prac-
tices. Denver, CO: The Association of Operating Room
Nurses, Inc; 1994:191-195.
5. Recommended practices for laser safety in practice set-
tings. In: Standards, Recommended Practices & Guide-
lines. Denver, CO: AORN, Inc; 1999:267-272.
6. Recommended practices for laser safety in practice set-
tings. In: AORN Standards, Recommended Practices &
Guidelines. Denver, CO: AORN, Inc; 2004:319-324.
7. Ball KA. Lasers: The Perioperative Challenge. 3rd ed.
Denver, CO: AORN, Inc; 2004.
8. American National Standard for Safe Use of Lasers in
Health Care Facilities. Orlando, FL: The Laser Insti-
tute of America; 2005.
9. Laser hazards. Occupational Safety and Health Admin-
istration. http://www.osha.gov/SLTC/laserhazards/. Ac-
cessed January 23, 2012.
10. NIOSH Hazard Control HC11: Control of smoke from
laser/electric surgical procedures. http://www.cdc.gov/
niosh/hc11.html. Accessed January 23, 2012.
11. Z136. 3-2005: Safe Use of Lasers in Health Care Fa-
cilities. Washington, DC: American National Standards
Institute; 2005.
12. New clinical guide to surgical fire prevention. Health
Devices. 2009;38(10):314-332.
13. Absten GT. Medical Laser Safety and Credentialing
Guidelines. Professional Medical Education Associa-
tion, Inc; 2007:70-101.
14. Surgical Smoke Evacuation Tool Kit. AORN, Inc.
http://www.aorn.org/Clinical_Practice/ToolKits/
Surgical_Smoke_Evacuation_ToolKit/Surgical_Smoke_
Evacuation_Tool_Kit.aspx. Accessed February 14,
2012.
15. Laser safety [self-assessment questionnaire 18]. Health-
care Risk Control. 2011;1. https://www.ecri.org/
Documents/RM/HRC_TOC/SAQ18.pdf. Accessed Janu-
ary 23, 2012.
16. L-125 Principles of Lasers and Laser Safety. Rockwell
Laser Industries. http://www.rli.com/training/course
.aspx?CourseID⫽29. Accessed January 23, 2012.
17. Laser Institute of America. http://lia.org/. Accessed Jan-
uary 23, 2012.
18. Laser Safety in the Perioperative Setting [DVD]. Den-
ver, CO: AORN, Inc; 2011.
19. Annex D. The safe use of high-frequency electricity in
health care facilities. In: Health Care Facilities Hand-
book. 10th ed. Quincy, MA: National Fire Protection
Association; 2005.
20. Houck PM. Comparison of operating room lasers: uses,
hazards, guidelines. Nurs Clin North Am. 2006;41(2):
193-218, vi.
21. Patient Safety Authority. Airway fires during surgery.
PA-PSRS Patient Safety Advisory. 2007;4(1):1, 4-6.
22. Andersen K. Safe use of lasers in the operating room—
what perioperative nurses should know. AORN J. 2004;
79(1):171-188.
AORN Journal 623
May 2012 Vol 95 No 5 CASTELLUCCIO

23. Occupational Health and Safety Administration. 29
CFR § 1910.132-134: General requirements; eye and
face protection; respiratory protection; 2008.
24. TJC makes it clear: get surgical smoke out of OR.
Same-Day Surgery. 2009;33(6):59-60.
25. Novak DA, Benson SM. Understanding and controlling
the hazards of surgical smoke. Becker’s ASC Review.
March 28, 2011. http://www.beckersasc.com/asc-
accreditation-and-patient-safety/understanding-and-
controlling-the-hazards-of-surgical-smoke.html. Ac-
cessed January 23, 2012.
26. ECRI Institute. Smoke evacuation systems, surgical.
Healthcare Product Comparison System. November
2007.
27. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Sur-
gical smoke and infection control. J Hosp Infect. 2006;
62(1):1-5.
28. Waddell AW. Cultivating quality: implementing surgi-
cal smoke evacuation in the operating room. Am J
Nurs. 2010;110(1):54-58.
29. Medical surveillance (rationale). In: Environmental
Health Criteria 23: Lasers and Optical Radiation. Ge-
neva, Switzerland: World Health Organization;
1982:132.
30. Oberg T, Brosseau LM. Surgical mask filter and fit per-
formance. Am J Infect Control. 2008;36(4):276-282.
31. Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/
FireSafety/. Accessed February 14, 2012.
32. Perioperative Job Descriptions and Competency Evalu-
ation Tools [CD-ROM]. Denver, CO: AORN, Inc;
2012.
33. Policy & Procedure Templates, 2nd ed [CD-ROM].
Denver, CO: AORN, Inc; 2010.
Donna Castelluccio, MSN, RN, CNOR, is an
OR educator, Danbury Hospital, Danbury, CT.
Ms Castelluccio has no declared affiliation that
could be perceived as posing a potential con-
flict of interest in the publication of this article.

This RP Implementation Guide is intended to be an adjunct to the complete recommended practices

document upon which it is based and is not intended to be a replacement for that document. Individu-
als who are developing and updating organizational policies and procedures should review and refer-
ence the full recommended practices document.

624 AORN Journal

EXAMINATION
CONTINUING EDUCATION PROGRAM

2.6
Implementing AORN Recommended www.aorn.org/CE

Practices for Laser Safety

PURPOSE/GOAL
To educate perioperative nurses about how to implement the AORN “Recommended
practices for laser safety in perioperative practice settings” in inpatient and ambu-
latory settings.

OBJECTIVES
1. Identify potential risks involved with the use of medical lasers.
2. Discuss AORN’s practice recommendations for the use and care of laser
equipment.
3. Discuss AORN’s practice recommendations for providing a safe environment for
patients and health care workers.
4. Describe methods for implementing AORN’s practice recommendations for laser
safety.
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 2. protect staff members and patients from unin-

1. Perioperative nurses must institute control mea- tentional exposure to the laser beam.
sures to minimize laser hazards such as 3. protect staff members and patients against
1. fire. electrical hazards.
2. injury to the eye from direct viewing or scat- 4. provide physicians with the clinical component
tered beams. of their laser training.
3. skin damage caused by burns. 5. provide staff members and patients with appro-
4. surgical smoke. priate safety eyewear.
a. 1 and 2 b. 3, 4, and 5
a. 1 and 2 b. 3 and 4
c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
c. 1, 3, and 4 d. 1, 2, 3, and 4

3. Responsibilities of the members of the laser

2. A laser safety program should include safety safety committee include ensuring a laser safety
measures to specialist is available for each area of laser use.
1. control access to laser use areas. a. true b. false

© AORN, Inc., 2012 May 2012 Vol 95 No 5 ● AORN Journal 625

May 2012 Vol 95 No 5 CE EXAMINATION

4. To implement safety recommendations in a facil- 8. To implement recommendations for ensuring

ity in which a laser safety program is already in proper laser safety measures, perioperative team
place, an interested perioperative nurse or the members can
laser safety officer should 1. create a resource book with information about
1. consider starting a laser safety awareness each laser in use at the facility.
campaign. 2. provide pictures of the various laser compo-
2. consider making a poster on the effects of sur- nents and directions for how to assemble them.
gical smoke to get staff members’ attention. 3. review laser safety precautions in a huddle
3. listen to staff member concerns about barriers before the patient enters the room or during
to implementation. the time out.
4. enlist the help of staff members who regularly 4. set up a laser cart so glasses, signs, masks, and
participate in laser procedures to motivate oth- other necessary items are located in one place.
ers to follow policy. a. 1 and 2 b. 3 and 4
a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
c. 1, 3, and 4 d. 1, 2, 3, and 4
9. Surgical smoke has been found to contain
5. One of the three practice recommendations that 1. bacterial and viral contaminants.
address control measures necessary for patient 2. cyanide.
and staff member safety is ensuring that all peo- 3. fiberglass.
ple in laser use areas wear the appropriate 4. formaldehyde.
eyewear. 5. polyicynene.
a. true b. false 6. toxic gases and vapors.
a. 1, 3, and 5 b. 1, 2, 4, and 6
c. 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
6. Practices to protect staff members and patients
from unintentional laser beam exposure include 10. During laser use, basic electrical and fire safety
a. requiring eyewear that is appropriate for multi- precautions must be followed, including
ple lasers. 1. checking wires for fraying, cracks, and breaks.
b. placing the foot switch near the operator. 2. keeping sponges and drapes near the surgical
c. shutting the laser off when it is not in use. site moist.
d. using reflective instruments near the laser site. 3. not putting liquids on the console.
4. using extension cords to minimize the risk of
7. The patient’s eyes should be covered with wet slips, trips, and falls.
eye pads if the treatment area is around the eyes. a. 1 and 2 b. 3 and 4
a. true b. false c. 1, 2, and 3 d. 1, 2, 3, and 4

626 AORN Journal

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended
Practices for Laser Safety
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 potential risks involved with the use of
medical lasers. Low 1. 2. 3. 4. 5. High
2. Discuss AORN’s practice recommendations for
the use and care of laser equipment.
Low 1. 2. 3. 4. 5. High
3. Discuss AORN’s practice recommendations for
providing a safe environment for patients and
health care workers.
Low 1. 2. 3. 4. 5. High
4. Describe methods for implementing AORN’s prac-
tice recommendations for laser safety.
Low 1. 2. 3. 4. 5. High
CONTENT
5. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
6. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
© AORN, Inc., 2012
2.6
www.aorn.org/CE
8. Will you change your practice as a result of
reading this article? (If yes, answer question
#8A. If no, answer question #8B.)
8A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regard-
ing 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:
8B. 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:
9. Our accrediting body requires that we verify
the time you needed to complete the 2.6 con-
tinuing education contact hour (156-minute)
program:
May 2012 Vol 95 No 5 ● AORN Journal 627