developing surgical checklist

7/25/2019 Developing Surgical Checklist

1/7

1.2www.aorn.org/CE

This Month

ff Developing a surgical checklist

Key words: surgical safety checklist, patient safety.

ff Updating a latex allergy policy and procedure

Key words: latex, allergy, sensitivity.

ff Establishing a policy and procedure for maintaining surgical

patient images

Key words: digital imaging, privacy, informed consent, patients rights.

ff Developing a surgical checklist

QUESTION:

We have assembled a multidisciplinary team to

develop a surgical checklist. The checklist willbe generic in form and tested in a select cohort

of surgical patients. Is there evidence to sup-

port using a checklist? What items should we

include in the checklist? We are using the

AORN Comprehensive Surgical Checklist,1 the

World Health Organization (WHO) Surgical

Safety Checklist,2 and the Joint Commission

Universal Protocol3 as guides.

ANSWER:

The use of a surgical checklist has been found to

affect patient safety in a variety of ways. One of

the better known research studies4 was conducted

to determine whether using the Surgical Safety

Checklist based on the WHO Guidelines for Safe

Surgery5 would improve team communication and

lead to reduced complications and death rates for

surgical patients. Facilities in eight cities around

the world, including Seattle, Washington, partici-

pated. Overall, there were improvements in surgi-

cal outcomes for patients at least 16 years of age

who underwent noncardiac inpatient surgeries.

Rates of postoperative complications (eg, deep

vein thrombosis, surgical site infection, unplanned

return to the OR) declined at all participating test

sites from 11% at baseline to 7% after implemen-

tation of the checklist.4

de Vries et al6 conducted a study in six hospi-

tals in The Netherlands to test the Surgical Patient

indicates that continuing education contact hours are available for this activity. Earn the contact hours by

reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at

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CLINICAL ISSUES

doi: 10.1016/j.aorn.2011.01.005

498 AORN Journal April 2011 Vol 93 No 4 AORN, Inc, 2011
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Safety System (SURPASS), a multidisciplinary

comprehensive checklist that was used from ad-

mission to discharge. After implementation of the

checklist, the total number of complications for

patients in all six hospitals decreased by 16.7%.

The study included a control group of five hospi-

tals in which complication and mortality rates did

not change significantly during the study period.

This result increased the likelihood that the com-

plication rates in the test group decreased as a

result of use of the checklist.

Lingard et al7 studied the effects of using a

perioperative checklist and team briefing on com-

munication. Surgeons, anesthesia professionals,

and nurses participated in a preoperative team

briefing in the form of a checklist for patients

undergoing elective general surgery. Trained ob-

servers collected data before and after implemen-

tation of the briefing. The outcome measure was

the total number of communication failures for

each surgical procedure. Most of the briefings

occurred either before or after induction of gen-

eral anesthesia. One of the more important find-

ings was that the number of communication

failures that were linked to at least one observed

negative consequence declined by 64% post-

intervention.

Berenholtz et al8 evaluated implementation of a

one-page briefing and debriefing tool to determine

its effect on team members perceptions. The sur-

gical team conducted the briefing portion after the

patient was positioned and before skin incision.

The circulating nurse conducted the debriefing

after the first closing count. The average lengths

of time were 2.9 minutes for the briefing and 2.5

minutes for the debriefing. Results showed that

team members recognized the value of the tool,

and its use improved interdisciplinary communi-

cation and teamwork.

Makary et al9 evaluated implementation of a

team briefing to determine its effect on team

members perceptions. Surgical personnel com-

pleted a questionnaire before and after implemen-

tation of an OR briefing program. Items in the

questionnaire related to coordination of care and

awareness of the surgical site. Results indicated

that after implementation of the OR team briefing,

surgical team members perceived that risk of

wrong site surgery was reduced and collaboration

among team members increased.

Several important questions will be generated

during the process of developing a checklist.

These questions will relate to

supportive evidence,

items to include on the list,

mandating use of the checklist,

team member buy-in,

implementation, and

quality measures.

The first step in developing a surgical checklist is

to review the current evidence on the topic. In

addition, an understanding of the workplace sys-

tems and needs of the team requires knowledge of

human factors engineering. Human factors engi-

neering is the study of how human capabilities

and limitations relate to a system, product, or pro-

cess. It recognizes that humans have limitations

and that these limitations should be factored into

the design of a safe, effective, and efficient sys-

tem.10 Knowledge of human factors engineering

leads to a better-developed checklist that is more

closely matched to the users needs.

Determining which items to include in the

checklist depends on several factors. It is impor-

tant to standardize the who, what, when, how, and

by whom.11 The team may begin by asking the

following questions while keeping in mind the

need to keep the checklist brief:

Are there specific items that must be included

because of regulatory or accreditation

requirements?

Is the item critical for patient safety?

Is the item a standard of care that is already

practiced?

Would the item be missed if it were not in-

cluded on the checklist?

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AORN Journal 499


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Are there specific items that have been identi-

fied as being performed inconsistently and

thus creating risks to patient safety?

Can certain items be bundled into one

checkpoint?

Many checklists are designed to address spe-

cific points in time (eg, preoperative, time out,

postoperative), so each time should be clearly

defined. For example, the purpose of the time out

is to facilitate communication and perform a final

check for identification of the correct patient, site,

and procedure. Team members may identify items

that are more critical at one point in time than at

another. Marking of the surgical site should be

completed during the preoperative phase, not afterthe patient is draped. There should be a section in

the checklist that allows the team members to intro-

duce themselves and freely speak up regarding any

concerns they have about the patient or process.

Open-ended questions should be encouraged (eg,

Are there any questions about specimens?).

The team should avoid creating the perception

that the checklist is nothing more than a series of

boxes to be checked off by rote. It is critical that

team members use the checklist because they be-lieve that it increases patient safety, not because

they are mandated to do so. Checklists can be paper

forms or part of an electronic health record. Some

facilities do not require an actual box to be checked,

and in some facilities, the checklist is not main-

tained as part of the patients health record.

After the checklist is developed, it should be pilot

tested. Quality measures should be used to evaluate

the usefulness of the checklist. Specific areas to

evaluate include the amount of time required tocomplete the list, negative effects on patient or care-

giver safety, and team member feedback.11 Team

members should recognize that the checklist is an

evolving tool that will change as newer evidence to

support patient safety practices becomes available.

AORN has several resources that can be used dur-

ing the development and implementation of a surgi-

cal checklist, including the Comprehensive Surgical

Checklist1; human factors,12 patient hand off13 and

correct site surgery14 tool kits; and the Recom-

mended practices for transfer of patient care

information.15

Editors note:Universal Protocol is a trademark ofthe Joint Commission, Oakbrook Terrace, IL.

ROBIN CHARD

PhD, RN, CNORPERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

References

1. AORN Comprehensive Surgical Checklist. AORN, Inc.

http://www.aorn.org/PracticeResources/ToolKits/Correct

SiteSurgeryToolKit/Comprehensivechecklist.Accessed

January 3, 2011.

2. Surgical Safety Checklist. World Health Organization.

http://whqlibdoc.who.int/publications/2009/97892415985

90_eng_Checklist.pdf.Accessed January 19, 2011.

3. Universal Protocol. The Joint Commission.http://www

.jointcommission.org/standards_information/up.aspx.

Accessed January 19, 2011.

4. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery

Saves Lives Study Group. A surgical safety checklist to

reduce morbidity and mortality in a global population.

N Engl J Med. 2009;360(5):491-499.

5. World Health Organization.WHO Guidelines for Safe

Surgery 2009: Safe Surgery Saves Lives. Geneva, Swit-

zerland: WHO Press; 2009:98.

6. de Vries EN, Prins HA, Crolla R, et al; SURPASS Col-

laborative Group. Effect of a comprehensive surgical

safety system on patient outcomes. N Engl J Med.2010;363(20):1928-1937.

7. Lingard L, Regehr G, Orser B, et al. Evaluation of a pre-

operative checklist and team briefing among surgeons,

nurses, and anesthesiologists to reduce failures in commu-

nication. Arch Surg. 2008;143(1):12-17.

8. Berenholtz SM, Schumacher K, Hayanga AJ, et al.

Implementing standardized operating room briefings

and debriefings at a large regional medical center. Jt

Comm J Qual Patient Saf. 2009;35(8):391-397.

9. Makary MA, Mukherjee A, Sexton JB, et al. Operating

room briefings and wrong site surgery. J Am Coll Surg.

2007;204(2):236-243.

10. Boston-Fleischhauer CB. Enhancing healthcare process

design with human factors engineering and reliabilityscience, part 1: setting the context. J Nurs Adm. 2008;

38(1):27-32.

11. Winters BD, Gurses AP, Lehmann H, Sexton JB,

Rampersad CJ, Provovost PJ. Clinical review: check-

liststranslating evidence into practice. Crit Care.

2009;13(6):210.

12. Human Factors in Health Care Tool Kit. AORN, Inc.

http://www.aorn.org/PracticeResources/ToolKits/Human

FactorsInHealthCareToolKit.Accessed January 3, 2011.

13. Perioperative Patient Hand-Off Tool Kit. AORN, Inc.

http://www.aorn.org/PracticeResources/ToolKits/Patient

HandOffToolKit.Accessed January 3, 2011.

April 2011 Vol 93 No 4 CLINICAL ISSUES

500 AORN Journal
http://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklisthttp://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklisthttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://www.jointcommission.org/standards_information/up.aspxhttp://www.jointcommission.org/standards_information/up.aspxhttp://www.jointcommission.org/standards_information/up.aspxhttp://www.aorn.org/PracticeResources/ToolKits/HumanFactorsInHealthCareToolKithttp://www.aorn.org/PracticeResources/ToolKits/HumanFactorsInHealthCareToolKithttp://www.aorn.org/PracticeResources/ToolKits/HumanFactorsInHealthCareToolKithttp://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKithttp://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKithttp://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKithttp://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKithttp://www.aorn.org/PracticeResources/ToolKits/HumanFactorsInHealthCareToolKithttp://www.aorn.org/PracticeResources/ToolKits/HumanFactorsInHealthCareToolKithttp://www.jointcommission.org/standards_information/up.aspxhttp://www.jointcommission.org/standards_information/up.aspxhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklisthttp://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist


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14. Correct Site Surgery Tool Kit. AORN, Inc.http://

www.aorn.org/PracticeResources/ToolKits/CorrectSite

SurgeryToolKit.Accessed January 3, 2011.

15. Recommended practices for transfer of patient care infor-

mation. In:Perioperative Standards and Recommended

Practices. Denver, CO: AORN, Inc; 2010:371-377.

ff Updating a latex allergy policy and procedure

QUESTION:

We are updating our policy and procedure for

patients with latex allergies. Are there new

practice changes that we should be aware of?

ANSWER:

A sharp increase in reported latex allergies began

in the late 1980s after implementation of standard

precautions by the Centers for Disease Control

and Prevention.1 The new precautions caused an

increase in the annual use of surgical gloves from

800 million to more than 20 billion.2 The in-

creased use of gloves and other latex products led

to an increase in natural rubber latex (NRL)-

associated reactions (eg, sensitivity, allergy), in-

cluding anaphylaxis. As a result, in 1997, the US

Food and Drug Administration required that all

medical devices containing latex be labeled as

such and carry a caution that latex can cause al-

lergic reactions.3 Since that time, practices such

as advanced identification of patients with latex

allergies, room preparation to minimize or avoid

use of latex products, and ensuring the availabil-

ity of latex-free products have become routine.

Currently, people who are sensitized to NRL

are grouped according to risk:

less than 1% of the general population in the

United States (ie, approximately 3 million

people);

8% to 17% of health care workers; patients who have undergone multiple surgical

procedures, and

up to 68% of children with spina bifida be-

cause of frequent surgeries.4

Latex allergies are defined as

type I (ie, immediate-type sensitivity);

type IV (ie, delayed-type hypersensitivity);

and

irritant contact dermatitis.

Type I is the most serious; reactions occur within

minutes of exposure. Routes of exposure include

direct external contact (ie, to gloves or other

latex products);

airborne exposure;

direct contact of the mucous membranes;

internal patient exposure from health care pro-

vider use of NRL gloves during surgical pro-

cedures; and

internally placed devices (eg, wound drains).5

People who have other types of allergies, such as

food allergies (eg, banana, kiwi, avocado), hay

fever, and asthma, also may be at increased risk

for NRL-associated reactions.6

Critical areas that should be addressed in a la-

tex allergy policy and procedure include

measures to identify patients at risk,

patient education, and interventions developed to reduce undue latex

exposure.

First and foremost, a latex-safe environment is

recommended. A latex-safe environment is one in

which every reasonable effort has been made to

prevent high-allergen and airborne latex sources

from coming into direct contact with affected in-

dividuals.7 Health care providers should assess all

patients undergoing a surgical or invasive proce-

dure for NRL-associated reactions. This can bedone by using a separate screening questionnaire

or can be included in the general preoperative

assessment tool. A patient who is identified as

latex sensitized or latex allergic should wear a

wristband, bracelet, or other form of identifica-

tion, and the patients health record and bed

should be labeled accordingly. Latex-free alterna-

tive items should be collected and stored in a


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quick-access location (eg, a cart) for ease of iden-

tification and use. As a result of the increased

number of latex-free products now available,

some facilities are becoming completely latex-

free, so a cart may not be needed to store latex-

free alternatives. Health care providers must com-

municate about the patients allergy or sensitivity

through all phases and transfers of care.

Some interventions remain controversial

because of limited or dated evidence. For exam-

ple, if the facility is latex safe, the patient with a

latex sensitivity need not be scheduled to undergo

the first procedure of the day. If the facility is not

latex safe, however, best practice would dictate

that the patient be scheduled first in the morning

because it is assumed that the inactivity in the

room during the previous evening hours causes

the content of latex-coated powder in the ambient

air to be lowest in the morning.8,9

The only safe treatment for individuals with

latex allergy or sensitivity includes complete

avoidance of latex.10 Attentive team members

supported by a strong policy and procedure can

provide a safe environment for patients who may

be at risk for NRL-associated reactions. The

AORN latex guideline7 provides additional in-

formation, including definitions, pathophysiology,

prevention strategies, and strategies for managing

latex-allergic individuals.

ROBIN CHARD



References

1. Centers for Disease Control. Recommendations for pre-vention of HIV transmission in health-care settings.

MMWR. 1987;36:S2.

2. Center for Devices and Radiological Health.Medical

Glove Powder Report. Rockville, MD: Food and Drug

Administration; 1987.

3. Natural rubber-containing medical devices; user

labelingFDA final rule. Fed Regist. 1997;62(189):

51021-51030.

4. Latex allergy statistics. American Latex Allergy Associ-

ation.http://www.latexallergyresources.org/topics

/LatexAllergyStatistics.cfm. Accessed December 10,

2010.

5. Weissman DN, Lewis DM. Allergic and latex-specific

sensitization: route, frequency, and amount of exposurethat are required to initiate IgE production. J Allergy

Clin Immunol. 2002;110(Suppl 2):57S-63S.

6. Brown R, Schauble J, Hamilton R. Prevalence of latex

allergy among anesthesiologists: identification of sensi-

tized but asymptomatic individuals. Anesthesiology.

1998;89(2):287-289.

7. AORN latex guideline. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc;

2010:555-570.

8. Lieberman P. Anaphylactic reactions during surgical

and medical procedures. J Allergy Clin Immunol. 2002;

110(Suppl 2):64S-69S.

9. Reider N, Kretz B, Menardi G, Ulmer H, Fritsch P.

Outcome of a latex avoidance program in a high-riskpopulation for latex allergya five-year follow-up

study. Clin Exp Allergy. 2002;32(5):708-713.

10. Demaegd J, Soetens F, Herregods L. Latex allergy: a

challenge for anaesthetists. Acta Anaesthesiol Belg.

2006;57(2):127-135.

ff Establishing a policy and procedure for maintaining surgical

patient images

QUESTION:

Which practices should our department have

in place regarding patient images that are

taken during minimally invasive surgery?

ANSWER:

New technology may drive practice changes, and

a facility should have a policy and procedure re-

lated to patient images (eg, videotaping, digital

images, photographs) that are taken during mini-

mally invasive surgery and other invasive pro-

cedures. Policy content should include, but not be

limited to,

disclosure of information,

access to and use of databases,

access to and use of images, and

data security.1

Additional information specific to images can in-

clude ownership rights, storage and release of

images, patient authorization for release, and pa-

tient informed consent.2 The policy must comply

April 2011 Vol 93 No 4 CLINICAL ISSUES

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with the Standards of Privacy and Security of the

Health Insurance Portability and Accountability

Act (HIPAA),3 which requires patient authoriza-

tion for the release of protected health informa-

tion for purposes beyond treatment, payment, and

health care operations.

Aside from regulations and laws, content to

include in the patient consent for imaging is

dependent on each health care organization. If

images are taken as part of a research study, an

institutional review board or HIPAA-directed pri-

vacy board should approve of taking the images.

This type of consent should be incorporated into

the overall consent that the patient signs to partic-

ipate in the research study.2

According to the Joint Commission, a health

care facility can film, photograph, or videotape

the patient but only if the patient or an individual

designated by the patient (eg, family member,

significant other) gives consent. If the patient or

designated individual is unable to give consent,

the facility may film, videotape, or photograph

patient care activities; however, the organization

must have a written policy stating that informed

consent is required before the patients film or

videotape can be used for any purpose.4 In the

event that the patient does not give consent, the

images should be destroyed or that portion which

contains patient information should be removed.

If photographs and digital images are kept in the

patients health record, confidentiality practices

should be in place as determined by the facility.

For example, depending on the size, photographs

and digital images can be kept in sealed enve-

lopes in the patient health record.2

As patient advocates, perioperative nurses are

concerned about privacy and confidentiality is-

sues for their patients. All policies and proce-

dures related to these concerns should have

clear language; adhere to existing laws, regula-

tion, and accreditation requirements; and be

subject to periodic review. The less ambiguous

perioperative nurses are about the interventions

to ensure patient privacy and confidentiality,

the more confident patients will be in entrusting

their care.

ROBIN CHARD



References

1. Recommended practices for minimally invasive surgery.

In: Perioperative Standards and Recommended Prac-

tices. Denver, CO: AORN, Inc; 2010:139-173.

2. American Health Information Management Association.

Practice brief. Patient photography, videotaping, and

other imaging (updated). J AHIMA. 2001;72(6):64M-

64Q.3. OCR Privacy Brief. Summary of the HIPAA Privacy

Rule. Washington, DC: US Department of Health and

Human Services; 2003.

4. Patient rights and informed consent when videotaping or

filming. The Joint Commission. http://www.jointcommission

.org/standards_information/jcfaqdetails.aspx?Standards

FaqId223&ProgramId1.Accessed December 10,

2010.

The author of this column has no declared affiliations that could be perceived as posing a potential

conflict of interest in the publication of this article.


AORN Journal 503
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CONTINUING EDUCATION PROGRAM

1.2

www.aorn.org/CEClinical Issues

This evaluation is used to determine the extent to

which this continuing education program met

your learning needs. The evaluation is printed

here for your convenience. To receive continuing ed-

ucation credit, you must complete the Learner

Evaluation online at http://www.aorn.org/CE. Rate

the items as described below.

PURPOSE/GOAL

To educate perioperative nurses about providing safe

nursing care throughout the perioperative continuum.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Discuss practices that could jeopardize safety in

the perioperative area.

Low 1. 2. 3. 4. 5. High

2. Discuss common areas of concern that relate to

perioperative best practices.

Low 1. 2. 3. 4. 5. High3. Describe implementation of evidence-based prac-

tice in relation to perioperative nursing care.

Low 1. 2. 3. 4. 5. High

CONTENT

4. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

7. Will you change your practice as a result of

reading this article? (If yes, answer question

#7A. If no, answer question #7B.)

7A. How will you change your practice?(Select all

that apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/im-

plement a policy and procedure.

3. I will plan an informational meeting with phy-

sicians to seek their input and acceptance of

the need for change.

4. I will implement change and evaluate the ef-

fect of the change at regular intervals until the

change is incorporated as best practice.

5. Other:

7B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)1. The content of 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:

8. Our accrediting body requires that we verify

the time you needed to complete the 1.2 con-

tinuing education contact hour (72-minute) pro-

gram:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center

approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this

activity for relicensure.

Event:#11008; Session:#4061 Fee:Members $6, Nonmembers $12

The deadline for this program is April 30, 2014.

Each applicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION

504 AORN Journal April 2011 Vol 93 No 4 AORN, Inc, 2011
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developing surgical checklist

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