implementing aorn recommended practices for a safe ... · continuing education implementing aorn...
TRANSCRIPT
CONTINUING EDUCATION
Implementing AORNRecommended Practices fora Safe Environment of Care
ANTONIA B. HUGHES, MA, BSN, RN, CNOR 2.2www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are
available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evalua-
tion at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feed-
back on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
Event: #13523
Session: #0001
Fee: Members $13.20, Nonmembers $26.40
The CE contact hours for this article expire August 31, 2016.
Purpose/GoalTo enable the learner to take an active role in implementing
recommended practices for a safe environment of care in his or
her perioperative practice setting.
Objectives
1. Explain strategies for safe patient handling.
2. Discuss elements of fire safety.
3. Describe precautions for safe use of electrical equipment.
4. Discuss appropriate use of clinical and alert alarms.
5. Describe precautions to avoid thermal injuries.
6. Explain actions to take for the patient with latex sensitivity.
7. Describe the components of a chemical hazard risk
assessment.
AccreditationAORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
http://dx.doi.org/10.1016/j.aorn.2013.06.007
� AORN, Inc, 2013
ApprovalsThis program meets criteria for CNOR and CRNFA
recertification, as well as other CE 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 activity
for relicensure.
Conflict of Interest DisclosuresMs Hughes 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 Liz Cowperthwaite, senior managing editor, and Rebecca
Holm, MSN, RN, CNOR, clinical editor, with consultation
from Susan Bakewell, MS, RN-BC, director, Perioperative
Education. Ms Cowperthwaite, 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 SupportNo sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as CE for registered nurses.
This recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
August 2013 Vol 98 No 2 � AORN Journal j 153
RECOMMENDED PRACTICES
Implementing AORNRecommended Practices
for a Safe Environmentof Care154 j AORN Journal �
ANTONIA B. HUGHES, MA, BSN, RN, CNOR 2.2
www.aorn.org/CEABSTRACT
Providing a safe environment for every patient undergoing a surgical or other invasive
procedure is imperative. AORN’s “Recommended practices for a safe environment of
care” provides guidance on a wide range of topics related to the safety of perioperative
patients and health care personnel. The recommendations are intended to provide
guidance for establishing best practices and implementing safety measures in all
perioperative practice settings. Perioperative nurses should be aware of risks related to
musculoskeletal injuries, fire, equipment, latex, and chemicals, among others, and
understand strategies for reducing the risks. Evidence-based recommendations can
give practitioners the tools to guide safe practice. AORN J 98 (August 2013) 154-163.
� AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.06.007
Key words: musculoskeletal injury, fire safety, electrical equipment, clinical alarm,
alert alarm, blanket-warming cabinet, solution-warming cabinet, latex, natural
rubber latex, methyl methacrylate bone cement, formalin.
The AORN “Recommended practices for
a safe environment of care”1 addresses
a broad range of safety topics, including
n musculoskeletal injury,
n fire safety,
n electrical equipment,
n clinical and alert alarms,
n blanket- and solution-warming cabinets,
n medical gas cylinders,
n waste anesthesia gases,
August 2013 Vol 98 No 2
n latex,
n chemicals, and
n hazardous waste.
The recommended practices (RP) document was
originally published in 1988 and has been revised
numerous times. It was revised most recently in 2012
to bring AORN’s recommendations up to date with
new evidence, guidelines, and regulatory changes.
This updated RP document is evidence rated.
Each individual reference is evaluated for strength
http://dx.doi.org/10.1016/j.aorn.2013.06.007
� AORN, Inc, 2013
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org
and quality, and each intervention is rated based
on the level of the supporting evidence. Although
the RP documents have previously been well re-
ferenced, the strength and quality of the evidence
were not always apparent to the reader. To begin
the evidence review process, a medical librarian
conducts a systematic literature search to locate
references related to the topic, including relevant
regulations and professional guidelines. The lead
author and a doctorally prepared evidence reviewer
evaluate each reference and assign each one an
appraisal score. Then the collective evidence that
supports each intervention statement is reviewed,
and a rating is assigned to the intervention. The
RP document has been accepted for inclusion in
the Agency for Healthcare Research and Quality
National Guideline Clearinghouse, a searchable
database of clinical practice evidence-based
guidelines and abstracts.
WHAT’S NEW
Educational Resources
n AORNguidance statement: Safe patient handling andmovement in
the perioperative setting. In: Perioperative Standards and Recom-
mended Practices. Denver, CO: AORN, Inc; 2013: 553-572.
n AORNVideo Library: Electrosurgery: Function, Practice & Safety
[DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all.
n AORN Video Library: Fire Prevention in the Perioperative Suite
[DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all.
n AORN Video Library: Latex in the Perioperative Setting: Strate-
gies for the Patient and Staff Safety [DVD]. http://cine-med.com/
index.php?nav¼aorn&cat¼all.
n Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/firesafety/.
n Periop 101Module: Natural Latex Sensitivity/Allergy. AORN, Inc.
http://www.aorn.org/PeriopModules/.
n Safe Patient Handling and Movement Tool Kit. AORN, Inc. http://
www.aorn.org/ToolKits.
n Workplace Safety Tool Kit. AORN, Inc. http://www.aorn.org/
ToolKits.
Web site access verified April 16, 2013.
Based on the literature re-
view and appraisal, the RP
document was updated to
reflect new evidence. Topics
included in the previous it-
eration of the RP document
have been expanded to ad-
dress additional aspects of
safety for patients and health
care personnel. For example,
Recommendation I, related
to occupational injuries for
health care providers, has
been expanded to include
examples of specific risk-
reduction strategies for
injury prevention. Recom-
mendation II, which ad-
dresses fire safety, now
includes the practice re-
commendation to conduct
a fire risk assessment before
every surgical procedure.
Recommendation III on the safe use of electrical
equipment includes the intervention of completing
regular inspections of equipment before use. In
Recommendation IV, the discussion of alert
alarms has been expanded and an intervention
added regarding the need to communicate any
change to the alarm default parameters. Recom-
mendation V recommends precautions to take in
the event of a malfunction in a blanket- or solution-
warming cabinet. The subject of latex safety has
been added to the RP document in Recommenda-
tion VIII. Care of the patient with a latex allergy
or sensitivity was previously addressed in the
“AORN latex guideline.”2 Recommendation IX
includes the requirement of conducting an annual
chemical risk assessment.
Other significant changes to the content of the
document include deleting topics that are addressed
in other RP documents. Topics previously included
in the “Recommended practices for a safe envi-
ronment of care” that are addressed in other RP
AORN Journal j 155
August 2013 Vol 98 No 2 HUGHES
documents include exposure to surgical smoke3,4;
exposure to chemotherapeutic agents5; incorrect
tubing connections5; and requirements for heating,
ventilation, and air conditioning.6 Exposure to
bloodborne pathogens7 and radiation safety8 are
also outside the scope of this RP document.
RATIONALE
Identifying safety issues is the first step in creating
and maintaining a safe perioperative environment.
The RP document not only identifies hazards
present for health care personnel and patients but
suggests risk-reduction strategies that can be put
into place before a problem occurs. Emphasis is
placed on assessing the environment for hazards
and understanding how to correct and report safety
issues. Perioperative nurses can use the RP docu-
ment to help educate team members about the
potential hazards in the environment and how to
mitigate risk. A multidisciplinary team can use this
RP document to guide development of a quality
management plan and to create policies and pro-
cedures for safety in the perioperative area.
DISCUSSION
Because this RP addresses a broad range of safety
topics, the topics discussed in this article are
limited to musculoskeletal injury, fire safety,
electrical equipment, alarms, blanket- and solution-
warming cabinets, latex safety, and chemicals. The
full RP document should be consulted for more
information on these topics and additional topics
that are not included in this article.
Recommendation I
Perioperative team members should take precau-
tions “to mitigate the risk of occupational injuries
that may result in death, days lost from work, work
restrictions, medical treatment beyond first aid, and
loss of consciousness.”1(p218) A significant hazard
for all health care workers is the risk of musculo-
skeletal injury. Working in the perioperative envi-
ronment may include performing tasks that are
forceful or repetitive, that require maintaining
156 j AORN Journal
awkward or static postures, or that involve physical
exertion (eg, carrying heavy equipment).9 In addi-
tion, surgical and invasive procedure rooms have
cords, booms, equipment on wheels, and the po-
tential for wet floors, all of which can present the
risk of slips, trips, and falls.
Perioperative personnel should consider ad-
ministrative, engineering, and behavioral controls
when developing strategies for injury prevention.
Administrative controls include educating per-
sonnel on ergonomic and safe patient handling
techniques, which can decrease overall occupa-
tional injuries.10 Engineering controls include
having appropriate patient handling equipment;
use of transfer devices should be the norm in the
organization. An example of a behavioral control
is eliminating clutter by bundling and covering
cables on the floor to reduce the risk of team
members tripping over exposed wires and tubes.11
The physical environment should be conducive
to safety. Adequate lighting, adequate storage,
and ceiling-mounted electric or hydraulic booms,
when feasible, can decrease the risk of injuries to
personnel.11-13 The perioperative nurse should be
aware of any potential hazards in the environment
and know where and how to report any deficiencies.
Recommendation II
“Potential hazards associated with fire safety in
the practice setting should be identified, and safe
practices for communication, prevention, suppres-
sion, and evacuation should be established and
followed.”1(p220) Each facility should have a writ-
ten fire prevention plan that is developed by a
multidisciplinary team. The plan should include
team members’ responsibilities, an evacuation
plan, and the frequency and content of fire
safety education.
AORN recommends performing a fire risk as-
sessment before each surgical procedure (Figure 1).
The RN circulator initiates the fire risk assessment,
during which the team pinpoints fire risks and
identifies ways to mitigate those risks. The elements
of the risk assessment should be shared with the
Fire Risk Assessment Tool
A fire risk assessment is performed by the surgical team. The surgical team will assess the patient for potential fire risks: open oxygen source, available ignition source, or surgical site above the nipple line.
Total Score:
3 = High risk 2 = Low risk with the potential to convert to high risk 1 = Low risk
RN circulator: Announce the risk assessment score to the other team members.
Team: Follow the Fire Safety Plan according to unit-specific standards.
Circle appropriate option Yes No
Surgical site above the xiphoid process 1 0
Open oxygen source (patient receiving supplemental oxygen via any variety of face mask or nasal cannula)
1 0
Available ignition source (electrosurgical unit, laser or fiber-optic light source)
1 0
Figure 1. A fire risk assessment tool can be usedbefore the start of each surgical procedure to de-termine whether the procedure includes a risk of fire.Printed with permission from Baltimore WashingtonMedical Center, Glen Burnie, MD.
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org
entire surgical team. The communication includes
identifying the use of ignition sources, potential
oxidizers, and fuel sources. These three elements,
which are necessary for a fire to occur, are known
as the fire triangle (Figure 2). Perioperative nurses
have influence over the fuel sources, which include
clothing, drapes, and prep solutions.
Perioperative nurses should help ensure that an
ignition source does not come into contact with
a fuel source.14 Examples include making sure
a holster device is available to keep the electrosur-
gical active electrode (ie, pencil) from contacting
the drapes when it is not in use and ensuring that
prep solution is dry before the surgeon activates
the electrosurgical device. The RN circulator and
scrub person should make sure that sterile saline
or water is available on the back table to douse
flames if needed.
Fire safety includes having clearly marked exits,
hallways with good egress, and readily available
fire extinguishers, as well as performing regularly
scheduled fire drills. Participating in fire drills
allows nurses and other team members to actively
learn and practice what to do during a fire, where
fire extinguishers are located, when to evacuate,
and the best route for evacuation. A representative
from the perioperative department should coor-
dinate a drill with local fire departments after
coordination with the facility’s fire safety officer.
Fire drills should include a review of the exit
path and how to use a fire extinguisher. The fire
safety officer should conduct a post-fire drill review
with the personnel who participated. The review
should include a discussion about how to safely
evacuate the area and protect patients.
Recommendation III
Perioperative team members should take precau-
tions “to mitigate the risk of injury associated with
the use of electrical equipment.”1(p224) If it is not
handled and cared for correctly, electrical equip-
ment presents a potential risk of fire or injury to
patients and health care personnel.15 For example,
a frayed cord or a cord separating from the plug
could convey an electrical shock or start a fire.
Personnel at every facility should have a mech-
anism in place for regularly inspecting new and
existing equipment for damage periodically and
before use. Perioperative nurses may be asked
to participate in the inspection or to gather neces-
sary equipment. Each facility should identify how
equipment is inspected and how personnel are
made aware that the inspection has been completed
(eg, an updated sticker). Personnel should also
assess the facility’s ability to provide the neces-
sary power source to the equipment. For example,
some equipment (eg, robotics, lasers) requires
specific electrical load capabilities.
Although the previous edition of this RP docu-
ment recommended that use of extension cords
be avoided, the new document allows for the
use of electrical extension cords when appro-
priate. The grade of wire and type of plug should
match the equipment and the facility power source.
Mismatched electrical characteristics can cause
AORN Journal j 157
Figure 2. The AORN Fire Triangle illustrates the threeelements necessary for a fire and the members ofthe perioperative team who frequently influence theelements. Reprinted from Perioperative Standardsand Recommended Practices with permission fromAORN, Inc, Denver, CO. Copyright ª 2013. All rightsreserved.
August 2013 Vol 98 No 2 HUGHES
damage to the equipment and overheating of
the cord.15
Recommendation IV
Alarms in the perioperative setting are intended
to alert personnel to changes in a patient’s clinical
status or to equipment malfunctions. Perioperative
team members should take precautions “to mitigate
hazards associated with non-functioning clinical
and alert alarms or with personnel failing to hear or
failing to act on alarms.”1(p225)
Perioperative nurses use clinical alarm systems
as an adjunct to patient care; however, The Joint
Commission has identified clinical alarms as a
source of potential harm for the patient if they
are not checked and used appropriately.16 Clinical
alarms should be set so that all personnel can hear
the audible alarm over competing noise.17,18 If
default parameters are changed on a clinical alarm,
there must be clear verbal and visual communica-
tion among personnel about what changes were
made. Perioperative RNs should help ensure that
158 j AORN Journal
any changes in the alarm parameters or tone are
included in the patient hand-off communication
between health care providers.19
In each organization, clinical engineering or
biomedical department personnel should develop
procedures for regular testing of clinical and alert
alarms,17,18 and perioperative nurses should un-
derstand how the facility reviews and tests alarms.
The testing may be performed at the beginning of
the day or on a set schedule. Perioperative nurses
also should collaborate with clinical engineering
personnel to help maintain an inventory of devices
with clinical alarms and track the testing of devices.
Recommendation V
A warm blanket may help comfort a patient and
mitigate anxiety during the surgical event; how-
ever, perioperative team members should take
precautions “to avoid thermal injuries related to
warming solutions, blankets, and patient linens
in blanket- and solution-warming cabinets.”1(p225)
Thermal injuries are a potential safety hazard in the
perioperative setting because patients are sedated
and may not be able to communicate any discom-
fort from overheated linens or solutions.
Warming cabinets should be labeled to identify
the items that may be placed in the cabinet. An
example is to label the outside of each cabinet
shelf to indicate the permitted contents (eg, blan-
kets on top, fluid on bottom).20 The temperature
of each unit should be set, monitored, maintain-
ed, and documented according to organizational
policy and manufacturers’ specifications. A man-
ual log may be used if the temperature is not
recorded via an electronic recording system. The
temperature reading should be visible to the per-
son retrieving the item from the warmer so he or
she can verify that the item is warmed to a safe
temperature. Any warmed item that is not the
correct temperature when removed from the war-
mer (ie, is too warm or too cold) may indicate that
the equipment is malfunctioning, and this should
be reported to clinical engineering or biomedical
department personnel.21
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org
Fluid-warming cabinets should be labeled
“for fluid only.” Fluid manufacturers have
recommendations for temperature settings and for
the length of time that fluids may be warmed
safely. Perioperative nurses should label any
solutions placed in a warming cabinet with the
date that the solution was placed in and removed
from the cabinet to help determine when the
solution has reached its maximum shelf life and
ensure it has not been in the warming cabinet
for longer than the solution manufacturer’s rec-
ommended warming time.20 “The temperature of
solutions on the sterile field should be remeasured
before administration.”1(p226) Solutions intended
for IV administration should be warmed only with
technology specifically designed to warm these
solutions because these may overheat if placed
in a warming cabinet.20,22
Recommendation VIII
The “AORN latex guideline”2 has been retired, and
the recommendations related to latex safety have
been updated and included in the current edition
of the “Recommended practices for a safe envi-
ronment of care.” The recommendation states,
“A protocol to establish a natural rubber latexesafe
environment should be developed and imple-
mented.”1(p229) An allergic reaction to latex could
cause a patient to experience anaphylaxis during
a surgical procedure.23-25 In addition, health care
personnel are frequently exposed to latex in the
surgical environment and thus are at risk for de-
veloping latex sensitivity.26 Latex exposure may
occur through contact with products containing
latex or through airborne particles. Perioperative
personnel should wear low-protein or powder-free
latex gloves or latex-free gloves to minimize their
own latex exposure.27
AORN’s latex recommendations include con-
ducting a thorough preoperative assessment of each
patient. In the assessment, the perioperative RN
should address at least the patient’s history of long-
term bladder care, history of multiple surgical
procedures, food allergies (eg, banana, kiwi,
avocado, chestnut, raw potato), and occupational
exposure to latex. Patients with latex sensitivity or
allergy should be identified with a bracelet or
wristband, on the medical record, and on the
patient’s bed. The patient should be scheduled
as the first patient of the day, because potentially
fewer latex proteins will be airborne in the OR if
no other procedures have been performed in the
OR that day.28
The perioperative RN can help provide the latex-
sensitive or -allergic patient with a latex-safe
environment by gathering non-latex products,
removing products that contain latex from the
room, and posting signs on the doors of the OR
to alert personnel that the patient has a latex
sensitivity or allergy. The nurse should include
a patient’s latex sensitivity or allergy in hand-off
communication to other health care personnel.24
When withdrawing medication from a vial, the
perioperative nurse should not remove the stopper
of the vial. In a review of the literature, no evidence
was found to support the practice of removing
medication vial stoppers to prevent contact with
latex in the stopper; the medications may already
contain latex from contact with the stopper during
transport and storage.25 The stopper should be
punctured only once to decrease the possibility of
introducing latex proteins into the medication.25
A multidisciplinary team approach should be
taken in caring for patients with latex sensitivity
or allergy. A member of the materials management
team should review current and potential purchases
of products containing latex with the clinical staff.
After the products are identified, clinical per-
sonnel on the value analysis team may be able
to assist with appropriate purchase selections for
latex-safe products.
Recommendation IX
Improper handling of chemicals can result in injury
to health care personnel and patients (eg, burns, eye
damage, respiratory problems). As required by the
Occupational Safety and Health Administration,29
health care personnel must take precautions “to
AORN Journal j 159
August 2013 Vol 98 No 2 HUGHES
mitigate the risks associated with the use of
chemicals in the perioperative setting (eg, methyl
methacrylate, glutaraldehyde, formalin, ethylene
oxide).”1(p231) The RP document provides guidance
on the use of each of these chemicals.
Health care organizations must follow the most
stringent of the federal, state, or local regulations
for chemical handling and disposal. Safety data
sheets, formerly called material safety data sheets,
must be readily accessible to employees within the
practice setting.29
The health care organization must annually per-
form a chemical hazard risk assessment within the
unit or facility that includes requirements for han-
dling, storing, and disposing of chemicals and for
managing spills and treating chemical exposures.29
Each perioperative health care provider has a re-
sponsibility to know how and where to seek infor-
mation regarding chemicals in his or her practice
setting. A hazardous chemical spill drill could be
performed in addition to annual fire safety drills.
The Final Four
The final four recommendations in each AORN RP
document discuss education/competency, docu-
mentation, policies and procedures, and quality
assurance/performance improvement, as appli-
cable. These four topics are integral to the imple-
mentation of AORN practice recommendations.
Personnel should receive initial and ongoing edu-
cation and competency validation as applicable
to their roles. Implementing new and updated rec-
ommended practices affords an excellent opportu-
nity to create or update competency materials and
validation tools. AORN’s perioperative competen-
cies team has developed the AORN Perioperative
Job Descriptions and Competency Evaluation
Tools30 to assist perioperative personnel in devel-
oping competency evaluation tools and position
descriptions.
Documentation of nursing care should include
patient assessment, plan of care, nursing diagnosis,
and identification of desired outcomes and inter-
ventions, as well as an evaluation of the patient’s
160 j AORN Journal
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 practices may present an
opportunity for collaborative efforts among nurses
and personnel from other departments within the
facility to develop organization-wide policies
and procedures that support the recommended
practices. The AORN Policy and Procedure
Templates, 3rd edition,31 provides a collection of
30 sample policies and customizable templates
based on AORN’s Perioperative Standards and
Recommended Practices.32 Quality assessment
and improvement activities assist in evaluating
the quality of patient care, the presence of environ-
mental safety hazards, and the formulation of plans
for taking corrective actions. 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 busy, six-room outpatient surgical facility
located in the Midwest routinely prepares its
patients with a preoperative telephone call. The
preoperative nurse asks the patient about health
history, including a family history of malignant
hyperthermia, and about medication and food
allergies. The patient receives education related
to the surgical procedure and surgeon preferences.
Ms D is a 35-year-old woman scheduled for
a laparoscopic umbilical hernia repair. The patient
is herself a perioperative RN, and during her pre-
operative assessment, she tells the preoperative
nurse that she has sensitivity to latex. The preop-
erative nurse immediately reports the patient’s
latex sensitivity to the perioperative team.
TheRNcirculator and the scrub person prepare the
OR according to the surgeon’s preferences and with
consideration for the patient’s latex sensitivity. They
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org
post signs stating “LatexAllergy” on theORdoors to
alert anyone entering the room. They examine each
item carefully to determine whether it contains any
latex and remove those that do from the OR, sub-
stituting latex-free alternatives. They complete the
counts, and the RN circulator goes to meet Ms D.
The nurse confirms the intended procedure with Ms
D, and they discuss her latex sensitivity. The RN
circulator explains that non-latex gloves will be used
and that all of the products in the room have been
inspected to make sure they do not contain latex.
A nursing diagnosis includes the potential for
hypothermia and retained foreign object and the
need to implement latex allergy precautions. A
forced-air warming device is placed on the patient
before the induction of anesthesia. The counts
are correct throughout the procedure. No signs
and symptoms of latex allergy are noted during
the procedure.
The patient’s surgery is completed without
complication. The RN circulator includes the
information about the patient’s latex sensitivity
in the hand-off report to the postanesthesia care
unit nurse. The patient recovers as expected and
meets all criteria for discharge to home.
Resources for Implementation
n AORN Syntegrity� Framework. AORN, Inc. http://www.aorn.org/
syntegrity.
n ORNurseLinkTM. http://ornurselink.aorn.org.
n Perioperative Job Descriptions and Competency Evaluation Tools
[CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/
JobDescriptions.
n Policy & Procedure Templates [CD-ROM]. 3rd ed. Denver, CO:
AORN, Inc; 2013.
n Ambulatory Surgery Center Resources [CD-ROM]. Denver, CO:
AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/
Ambulatory_Surgery_Center_Resources.aspx
Editor’s notes: AORN Syntegrity is a registered trademark and
ORNurseLink is a trademark of AORN, Inc, Denver, CO.
Web site access verified April 16, 2013.
HOSPITAL PATIENTSCENARIO
The environmental safety
manager, OR manager, chief
of anesthesia, and perioper-
ative educator in an urban,
mid-Atlantic community
hospital plan to conduct an
unannounced fire drill. The
hospital safety officer notifies
the local fire department and
the insurance carrier with the
date and time of the event.
The time is scheduled as
an inservice education pro-
gram for personnel from
the surgical and anesthesia
departments; however, the
participants are unaware that the subject of the
education program will be a fire drill. On the day of
the drill, perioperative personnel are separated into
three rooms, and each room has an assigned leader
who distributes scripts for the drill. The leader
assigns each person a role (ie, RN circulator, scrub
person, surgeon, anesthesia professional, nursing
assistant, student) before the scenario starts.
In room one, the group scenario describes a
patient undergoing a tracheostomy on a patient
care bed when the bed begins to emit smoke from
the motor area. The leader watches how group
members respond to the situation. Several team
members leave the room in search of fire extin-
guishers and to alert the charge nurse. The leader
determines that too much time lapses and de-
clares that everyone in the room died from
smoke inhalation.
In room two, the group scenario describes
a patient undergoing an upper body procedure
when the electrosurgical device begins to shoot
flames across the room. This group quickly pulls
the fire box alarm and gathers up the patient to
evacuate the room. They choose to leave by an old,
unused loading dock exit because the exit is close
AORN Journal j 161
August 2013 Vol 98 No 2 HUGHES
to the main OR doors. The group members discover
that they cannot bring the patient, who is on the OR
bed, down the blocked ramp. The scenario ends at
this point because the team is not successful in
evacuating the patient.
In room three, the group scenario describes a fire
that develops during a surgical procedure because
the electrosurgical active electrode (ie, pencil)
lying on the drape is accidentally activated and
ignites the drapes that are covering the patient.
The group members are able to smother the flames
with normal saline from the back table. They
elect not to evacuate the patient because the fire
has been extinguished. The drapes are removed
from the patient and the patient is assessed for
injury. It is determined that the patient has not been
injured. The patient is re-draped and the sterile field
re-established. The procedure is resumed.
After all three scenarios conclude, the safety
officer conducts a post-drill briefing with all
involved personnel. They evaluate each scenario
and highlight the weak points. In the first scenario,
the patient should have been transferred quickly
from the bed to a stretcher or to another OR bed.
The smoking bed should have been isolated and the
fire extinguished. The second group relates that they
tried to evacuate, but the exit ramp was blocked,
which taught the group that the loading dock exit is
only safe for personnel and patients who can walk.
The third group reacted the fastest to their scenario.
Lessons learned from that scenario were that fire can
erupt very quickly and the response must be fast to
prevent harm.
CONCLUSION
The AORN “Recommended practices for a safe
environment of care”1 encompasses a wide range of
topics, and the importance of a safe environment of
care is clearly outlined. Each topic in the document
can have a significant effect on patient and personnel
safety. Key takeaways include the following:
n Musculoskeletal injuries often can be prevented
with the use of transfer devices and other
measures.
162 j AORN Journal
n Fire safety involves the entire health care team;
vigilance with each patient interaction will lead
to a reduced risk of surgical fires.
n Health care team members should use electrical
devices and components safely and correctly to
avoid potential harm.
n Clinical alarms and alert alarms can notify
personnel of a patient’s changing condition or
an equipment malfunction as long as they can
be heard above competing noise.
n Perioperative team members should know how
to monitor and maintain correct temperatures in
warming devices.
n Screening patients for latex sensitivity or allergy
before surgery and using latex-safe products
increases the safety of the environment.
n Improper handling of chemicals can result in
injury to health care workers and patients.
Safety data sheets must be readily accessible
to health care workers for every potentially
hazardous chemical in the practice setting.
The “Recommended practices for a safe envi-
ronment of care” outlines how perioperative
personnel should practice within the recommen-
dations. Perioperative nurses should review the
RP document with their colleagues and managers
to help develop clear and comprehensive policies
and procedures for their facilities. Health care
workers and patients expect and deserve a safe
environment.
References1. Recommended practices for a safe environment of care.
In: Perioperative Standards and Recommended Prac-
tices. Denver, CO: AORN, Inc; 2013:217-241.
2. AORN latex guideline. In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc; 2012:
605-620.
3. Recommended practices for electrosurgery. In: Peri-
operative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2013:125-141.
4. Recommended practices for laser safety in the peri-
operative practice setting. In: Perioperative Standards
and Recommended Practices. Denver, CO: AORN, Inc;
2013:143-156.
5. Recommended practices for medication safety. In:
Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2013:255-293.
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE www.aornjournal.org
6. Recommended practices for a safe environment of care:
part II. In: Perioperative Standards and Recommended
Practices. Denver, CO: AORN, Inc. In press.
7. Recommended practices for prevention of transmissible
infections in the perioperative practice setting. In: Peri-
operative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2013:331-363.
8. Recommended practices for reducing radiological expo-
sure in the perioperative practice setting. In: Perioper-
ative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2013:295-304.
9. Esser AC, Koshy JG, Randle HW. Ergonomics in office-
based surgery: a survey-guided observational study.
Dermatol Surg. 2007;33(11):1304-1313.
10. Reddy PP, Reddy TP, Riog-Francoli J, et al. The
impact of the Alexander technique on improving
posture and surgical ergonomics during minimally
invasive surgery: pilot study. J Urol. 2011;186(4
suppl):1658-1662.
11. Cappell MS. Accidental occupational injuries to en-
doscopy personnel in a high-volume endoscopy suite
during the last decade: mechanisms, workplace hazards,
and proposed remediation. Dig Dis Sci. 2011;56(2):
479-487.
12. van Det MJ, Meijerink WJ, Hoff C, Tott�e ER, Pierie JP.
Optimal ergonomics for laparoscopic surgery in mini-
mally invasive surgery suites: a review and guidelines.
Surg Endosc. 2009;23(6):1279-1285.
13. AORN guidance statement: Safe patient handling and
movement in the perioperative setting. In: Perioperative
Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2013:553-572.
14. Rinder CS. Fire safety in the operating room. Curr Opin
Anaesthesiol. 2008;21(6):790-795.
15. NFPA 99: Health Care Facilities Code Handbook.
Quincy, MA: National Fire Protection Association;
2012.
16. Medical device alarm safety in hospitals. Sentinel Event
Alert. April 8, 2013;50. http://www.jointcommission
.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF.
Accessed June 13, 2013.
17. Clinical Alarms Task Force. Impact of clinical alarms on
patient safety: a report from the American College of
Clinical Engineering Healthcare Technology Foundation.
J Clin Eng. 2007;32(1):22-33.
18. A Siren Call to Action: Priority Issues from the Medical
Device Alarms Summit. Arlington, VA: Association for
the Advancement of Medical Instrumentation; 2011.
19. Brown JC, Anglin-Regal P. Clinical alarm management:
a team effort. Biomed Instrum Technol. 2008;42(2):
142-144.
20. Warming cabinets. Oper Room Risk Manag. 2010;
2(Surgery 7). https://www.ecri.org/Documents/RM/
ORRM_TOC/SU7ES.pdf. Accessed June 19, 2013.
21. Huang S, Gateley D, Moss AL. Accidental burn injury
during knee arthroscopy. Arthroscopy. 2007;23(12):1363.
e1-1363.e3.
22. Limiting temperature settings on blanket and solution
warming cabinets can prevent patient burns. Health
Devices. 2005;34(5):168-171.
23. Pollart SM, Warniment C, Mori T. Latex allergy. Am
Fam Physician. 2009;80(12):1413-1418.
24. Mertes PM, Lambert M, Gu�eant-Rodriguez RM, et al.
Perioperative anaphylaxis. Immunol Allergy Clin North
Am. 2009;29(3):429-451.
25. Heitz JW, Bader SO. An evidence-based approach to
medication preparation for the surgical patient at risk
for latex allergy: is it time to stop being stopper poppers?
J Clin Anesth. 2010;22(6):477-483.
26. Lieberman P, Nicklas RA, Oppenheimer J, et al. The
diagnosis and management of anaphylaxis practice
parameter: 2010 update. J Allergy Clin Immunol. 2010;
126(3):477-480.
27. Power S, Gallagher J, Meaney S. Quality of life in health
care workers with latex allergy. Occup Med (Lond).
2010;60(1):62-65.
28. Bernardini R, Catania P, Caffarelli C, et al. Perioper-
ative latex allergy. Int J Immunopathol Pharmacol.
2011;24(3 suppl):S55-S60.
29. Occupational Safety and Health Standards. Toxic and
hazardous substances: hazard communication. 29 CFR
x1910.1200. Occupational Safety and Health Adminis-
tration. http://www.osha.gov/pls/oshaweb/owadisp.show
_document?p_table¼STANDARDS&p_id¼10099. Ac-
cessed April 9, 2013.
30. Perioperative Job Descriptions and Competency Evalu-
ation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012.
31. Policy and Procedure Templates [CD-ROM]. 3rd ed.
Denver, CO: AORN, Inc; 2013.
32. Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2013.
Antonia B. Hughes, MA, BSN, RN, CNOR, is
a perioperative education specialist, Baltimore
Washington Medical Center, Edgewater, MD.
Ms Hughes has no declared affiliation that could
be perceived as posing a potential conflict 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. Individuals who are developing and
updating organizational policies and procedures should review and reference the full recommended practices
document.
AORN Journal j 163
EXAMINATION
CONTINUING EDUCATION PROGRAM2.2
www.aorn.org/CEImplementing AORN RecommendedPractices for a Safe Environmentof Care
PURPOSE/GOAL
16
To enable the learner to take an active role in implementing recommended prac-
tices for a safe environment of care in his or her perioperative practice setting.
OBJECTIVES
1. Explain strategies for safe patient handling.
2. Discuss elements of fire safety.
3. Describe precautions for safe use of electrical equipment.
4. Discuss appropriate use of clinical and alert alarms.
5. Describe precautions to avoid thermal injuries.
6. Explain actions to take for the patient with latex sensitivity.
7. Describe the components of a chemical hazard risk assessment.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Educating perioperative personnel on ergonomic
and safe patient handling techniques to prevent
injuries is an example of
a. an administrative control.
b. a behavioral control.
c. an engineering control.
d. a work practice control.
2. A fire risk assessment performed before each
surgical procedure includes
1. pinpointing fire risks.
2. identifying ways to mitigate fire risks.
4 j AORN Journal � August 2013 Vol 98 No 2
3. sharing the elements of the risk assessment
with the entire surgical team.
4. identifying the use of ignition sources,
potential oxidizers, and fuel sources.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 4 d. 1, 2, 3, and 4
3. The element of the fire triangle that perioperative
nurses most commonly have influence over is
a. the fuel source.
b. the ignition source.
c. the oxidizer.
4. The elements of a fire drill should include
1. the location of fire extinguishers.
� AORN, Inc, 2013
CE EXAMINATION www.aornjournal.org
2. how to use a fire extinguisher.
3. the best route for evacuation.
4. a post-fire drill review.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
5. Electrical extension cords may be used in the
OR when appropriate as long as the grade of wire
and type of plug match the equipment and the
facility power source.
a. true b. false
6. Changes to the default parameters of a clinical
alarm should be communicated
1. during the patient hand off.
2. to The Joint Commission.
3. verbally.
4. visually.
a. 1 and 2 b. 3 and 4
c. 1, 3, and 4 d. 1, 2, 3, and 4
7. Perioperative nurses should label any solutions
placed in a warming cabinet with the date that the
solution was
1. placed in the cabinet.
2. purchased.
3. removed from the cabinet.
4. manufactured.
a. 2 and 4 b. 1 and 3
c. 1, 2, and 3 d. 1, 2, 3, and 4
8. Topics related to latex sensitivity that the peri-
operative RN should address during the preoper-
ative assessment include
1. food allergies.
2. a history of multiple surgical procedures.
3. occupational exposures.
4. risk factors for malignant hyperthermia.
a. 1 and 4 b. 2 and 3
c. 1, 2, and 3 d. 1, 2, 3, and 4
9. Perioperative personnel should remove the stopper
from medication vials before withdrawing medi-
cation to reduce the potential for contaminating
the medication with latex proteins.
a. true b. false
10. The chemical hazard risk assessments should
include requirements for
1. handling chemicals.
2. managing chemical spills.
3. storing chemicals.
4. treating chemical exposures.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 4 d. 1, 2, 3, and 4
AORN Journal j 165
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM2.2
www.aorn.org/CEImplementing AORN RecommendedPractices for a Safe Environmentof Care
1
1
This 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. Explain strategies for safe patient handling.
Low 1. 2. 3. 4. 5. High
2. Discuss elements of fire safety.
Low 1. 2. 3. 4. 5. High
3. Describe precautions for safe use of electrical
equipment. Low 1. 2. 3. 4. 5. High
4. Discuss appropriate use of clinical and alert alarms.
Low 1. 2. 3. 4. 5. High
5. Describe precautions to avoid thermal injuries.
Low 1. 2. 3. 4. 5. High
6. Explain actions to take for the patient with latex
sensitivity. Low 1. 2. 3. 4. 5. High
7. Describe the components of a chemical hazard risk
assessment. Low 1. 2. 3. 4. 5. High
CONTENT
8. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
9. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High
10.Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
166 j AORN Journal � August 2013 Vol 98 No 2
11. Will you change your practice as a result of reading
this article? (If yes, answer question #11A. If no,
answer question #11B.)
1A. 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: ________________________________
1B. 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: ________________________________
12. Our accrediting body requires that we verify
the time you needed to complete the 2.2 con-
tinuing education contact hour (132-minute)
program: _________________________________
� AORN, Inc, 2013