SPECIAL TOPIC

Patient Safety in the Operating Room:I. PreoperativeSamuel O. Poore, M.D., Ph.D.

Nyama M. Sillah, M.D.Ashish Y. Mahajan, M.D.Karol A. Gutowski, M.D.

Madison, Wis.; Wilkes-Barre, Pa.; andGlenview, Ill.

Background: Beyond the controlled trauma of surgery, the operating room canbe a hazardous place for patients and health care workers alike. Modern plasticsurgery requires a thorough knowledge of various perioperative risks and meth-ods to minimize these risks. As the importance of teamwork becomes moreevident, clear communication skills preoperatively, intraoperatively, and post-operatively become equally critical. To facilitate an improvement in perioper-ative patient safety, this article will review aspects of communication, includingcrew resource management, root cause analysis, and surgical-site verification. Inaddition, the authors will discuss patient positioning, antiseptic hand and pa-tient preparations, and barriers, such as surgical scrubs, gowns, gloves, anddrapes.Methods: The authors reviewed the literature regarding operating room safety,both primary research and secondary reviews, via multiple PubMed queries andliterature searches. Topics most relevant to inpatient plastic surgery were in-cluded in the final analysis and summarized, as a full review of each topic isbeyond the scope of this article.Results: Many possible interventions were identified, with the goal of reducingperioperative complications, such as wrong site surgery, neuropathies, myopa-thies, compartment syndromes, pressure ulcers, surgical-site infections, andblood-borne disease transmissions among plastic surgeons and their patients.Conclusions: There are ample opportunities for the reduction of preventableadverse events in plastic surgery. This article aims to provide its reader with thetools to research adverse events and a basic education in avoiding specificpreoperative events. A second article addressing intraoperative and postoper-ative patient safety follows. (Plast. Reconstr. Surg. 130: 1038, 2012.)

The landmark report To Err Is Human: Buildinga Safer Health System by the Institute of Med-icine estimated that approximately 44,000 to

98,000 Americans die annually secondary to pre-ventable medical errors costing approximately$79 billion.1 Preventable medical errors alsocause great morbidity to patients. This articleand the one following it are designed to reviewvarious aspects that relate to patient safety in theinpatient operating room to identify modifiablefactors that can be improved to decrease pre-ventable medical errors.

THE IMPACT OF COMMUNICATIONMany preventable medical errors are the result

of communication failure. The Joint Commissionreported in 2006 that 70 percent of all sentinelevents in health care, which are unexpected oc-currences involving death or serious physical orpsychological injury, stem from communicationfailures (Fig. 1).2–4

Multiple articles have demonstrated commu-nication breakdowns in the operating room. In astudy by Lingard et al., 48 surgical cases were ob-served during which 421 communication eventswere identified.5 One-third of these were con-sidered communication “failures.” In reviewingclosed malpractice claim files, Greenberg et al.From the Division of Plastic and Reconstructive Surgery,

Department of Surgery, University of Wisconsin; Plastic andReconstructive Surgery, Geisinger Wyoming Valley; and pri-vate practice.Received for publication February 1, 2012; accepted May 25,2012.Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31826945d6

Disclosure: The authors have no financial inter-ests to declare. No funding was obtained or utilizedfor the research and writing of this article.

www.PRSJournal.com1038

analyzed 60 cases involving 81 communicationbreakdowns.6 Ninety-two percent of the commu-nication breakdowns were verbal, the majority ofwhich involved a single transmitter and receiver.Ambiguity about delegation of responsibility wasthe factor most commonly associated with com-munication breakdown. In the recently publishedAmerican College of Surgeons Closed ClaimsStudy, 90 of 460 claims were largely because ofcommunication failures. Errors resulting in claimsinclude wrong site surgery, retained foreign bod-ies, inappropriate use of medication, and misseddiagnoses. Interestingly, in 25 percent of the casesthe standard of care was met, but failed commu-nication “led to anger, mistrust, and litigation.”7

CREW RESOURCE MANAGEMENT ANDSENTINEL EVENTS

The Institute of Medicine’s report, in additionto identifying multiple mechanisms to avoid med-ical errors, included recommendations to adoptan aviation approach to safety and error manage-ment known as crew resource management. Theconcept of crew resource management grew fromthe recognition that between 50 and 80 percentof all aviation incidents and accidents are mostlycaused by human, rather than mechanical, errors.8Though crew resource management was initiallycreated for airline cockpits, it was subsequentlyadopted by many other industries. The FederalAviation Administration defines crew resourcemanagement as follows:

The utilization of all available human, informa-tional, and equipment resources toward the effectiveperformance of a safe and efficient flight. Crewresource management is an active process by crewmembers to identify significant threats to an opera-tion, communicate them to a person in charge, andto develop, communicate, and carry out a plan toavoid or mitigate each threat.8

Since being widely introduced into the airlineindustry, crew resource management has beenshown to improve performance, safety, commu-nication, and morale and to decrease accidentsrelated to crew error.

The concepts of crew resource managementhave also been applied to medicine and beenshown to improve safety. For example, MethodistUniversity Hospital in Memphis, Tennessee, en-listed crew resource management and targetedsponge counts as a measurement of outcome.They demonstrated that after the employment ofcrew resource management, there was a 50 per-cent reduction in counting errors 6 months fol-lowing training.9 Vanderbilt University MedicalCenter used crew resource management as a train-ing tool and then evaluated the attitudes and re-actions to this management of nearly 500 person-nel from trauma, surgery, emergency medicine,and administration; 95 percent believed that crewresource management training would reduce er-rors in their practice. Another study that em-ployed this training for emergency department

Fig. 1. Percentage of preoperative and postoperative sentinel events classified by root cause. Re-printed with permission from The Joint Commission Report 2006 (Powell SM, Hill RK. My copilot isa nurse: Using crew resource management in the OR. AORN J. 2006;83:179 –180, 183–190, 193–198 passim; quiz 203–206).

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staff showed a 58 percent reduction in observableerrors.10

CREW RESOURCE MANAGEMENTIMPLEMENTATION: EMPLOYINGEFFECTIVE OPERATING ROOM

COMMUNICATIONThere is an increasing push for crew resource

management implementation in health care as ameans of improving safety, and surgeons shouldbe aware of several key aspects (Table 1).4 Toincorporate crew resource management, many in-stitutions are developing briefing/debriefing pro-tocols. The Veterans Hospital Administrationlaunched a medical team training program in op-erating rooms at various institutions. Some out-comes evaluated were antibiotic and deep venousthrombosis prophylaxis compliance rates. Im-provements were found after training.11 The SanFrancisco Veterans Administration Medical Cen-ter found improvements in areas such as de-creased delays in cases and improved staff percep-tions of communication and patient safety afterparticipating in medical team training.12 Studieshave shown that for briefing/debriefing to be ef-fective, a safe environment must be established inwhich everyone feels comfortable expressing opin-ions, no matter rank.13 In a study by Papaspyros etal., implementation of briefing/debriefing ses-sions were conducted with staff cardiac surgeryteams. All team members were given chances totalk. Team members felt the briefing/debriefingprocess promoted professionalism and improved

communication.14 Briefing/debriefing sessionscan be a practical way to implement crew resourcemanagement.

SURGICAL-SITE IDENTIFICATION:SAFEGUARDING AGAINST WRONG

SITE SURGERYAlthough effective communication is an es-

sential starting point to improving patient safety,many aspects of preoperative care can also be tar-geted to improve patient safety. Wrong site surgeryis one of the top five most reported sentinel eventsidentified by The Joint Commission.15 The JointCommission’s sentinel event database has re-corded 150 cases of wrong site, wrong person, andwrong procedure surgery.16 The common rootcause of all these events was poor communication.

A recent retrospective review of multiple da-tabases reveals far more staggering numbers re-lated to wrong patient adverse events. Seiden andBarach estimated that there are between 1300 and2700 cases of wrong site and wrong person surgeryor near misses per year in the United States.17 Thisultimately led The Joint Commission to develop auniversal protocol to prevent these events (Fig.2).18 Current recommendations are: Before anysurgical procedure, there must be a preoperativeverification process to ensure all team membersverify the correct site, correct person, and thecorrect operation. Marking the incision siteshould be performed by the surgeon with the pa-tient awake and involved. Particular attentionshould be paid in cases involving left/right dis-

Table 1. Crew Resource Management, Communication Goals, Key Definitions, and Benefits*

Communication Goal Definition Benefit

Briefings A dialogue prior to a surgical case/procedurethat creates a shared mental model on whichall crew members are involved and sets theappropriate tone for upcoming events

Establishes the team concept, covers pertinentsafety and operational issues, identifiespotential problems, and includes new crewmembers as a part of the team

Inquiry Systemic investigation of facts or principles,or the requesting of information

Allows for open and nonhostile dialoguesregarding potentially unsafe situations

Advocacy Pleading or supporting a cause or proposal Allows for individuals to campaign for thecourse of action that they feel is best, evenif it conflicts with others

Assertion Positively stating or declaring something inanticipation of denial or objection

Provides a nonhostile method of persistentinquiry into situations that maybepotentially unsafe

Self-critique The process by which crew members reviewevents, provide feedback, and evaluate eachother using nonhostile methods

Provides a safety net that through communicationencourages the crew to identify, control,recover, and learn from errors

Conflict resolution The process by which disputes and conflictsare resolved

Empowers team members to voice theiropinions or concerns for any given situationwithout being punished or humiliated

Decision making The cognitive process leading to the selectionof a course of action among alternatives

*Adapted from Powell SM, Hill RK. My copilot is a nurse: Using crew resource management in the OR. AORN J. 2006;83:179–180, 183–190,193–198 passim; quiz 203–206.

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Fig. 2. The Joint Commission universal protocol for preventing wrong site, wrong procedure, and wrong personsurgery. From The Joint Commission. Universal protocol. Available at: http://www.jointcommission.org/assets/1/18/UP_Poster1.pdf. Accessed January 30, 2012. Copyright © The Joint Commission, 2012. Reprinted with permis-sion.

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tinction and with multiple levels. Finally a “timeout,” which is active communication among allmembers of the team, should be performed as afinal effort to verify correct site, person, and op-eration.

Recently, the World Health Organization im-plemented the “Safe Surgery Saves Lives Chal-lenge” that includes a universal surgical safetychecklist (Fig. 3).19 A prospective study by Hayneset al. gathered data from eight hospitals in eightcountries worldwide that participated in theWorld Health Organization challenge. Theyfound a statistically significant decrease in thedeath rate from 1.5 to 0.8 percent and the com-plication rate from 11 to 7 percent after imple-mentation of the surgical safety checklist.20 De-spite these significant nationwide efforts, there isstill convincing evidence that wrong site surgeryis actually on the rise. From January 1st to thethird quarter of 2011, it was one of the mostfrequent Joint Commission sentinel events, with115 cases investigated.21 This demonstrates theneed for further education of all operatingroom personnel.

PATIENT POSITIONINGAlthough the risks of improper patient posi-

tioning seem obvious, including peripheral neu-ropathies, brachial plexopathies, myopathies,compartment syndromes, and pressure ulcers, at-tention to specific patient characteristics and id-iosyncrasies of common positions can help pre-vent these complications. This is especially true inplastic surgery, for which unusual positioning maybe required for adequate exposure.

Several patient factors increase surgical riskregardless of position, including advanced age;extremes of height and weight; comorbidities,such as diabetes, pulmonary disease, or cardio-vascular compromise; poor nutritional status;prolonged hospitalization; and preexisting lim-itations of movement. These same characteris-tics also predispose a patient to positioningcomplications.22 In the supine or Trendelenbergpositions, significant chest bulk combined withdeep anesthesia may induce Pickwickian physiol-ogy and compromise respiratory function. Ca-chexia may produce bony prominences, predis-

Fig. 3. Surgical safety checklist provided by the World Health Organization as part of the “Safe Surgery Saves Lives” campaign.Reprinted with permission from the World Health Organization. Patient safety. Available at: http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf. Accessed March 2011.

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posing a patient to compressive neuropathies orpressure ulcer formation. Preoperatively, severalfactors should be noted and assessed in an effortto the select the safest position for the patientincluding: (1) body habitus; (2) preoperative skincondition; (3) comorbid illnesses; (4) existing pe-ripheral neuropathies; (5) limitations in move-ment; and (6) prior procedures, positions, andcomplications. Surprisingly, the incidence of sur-gically acquired pressure ulceration ranges from4.5 to 26 percent. A large survey by Aronovitchshowed an 8.5 percent incidence in cases lasting atleast 3 hours.23 There are several intraoperativefactors that may be minimized to prevent pressureulcers, including: (1) hypotension or local hypo-perfusion; (2) local pressure in excess of 32mmHg (this value reflects the average capillaryperfusion pressure in healthy tissue and may be aslow as 12 mmHg in the presence of peripheralvascular disease); (3) layers, such as a warmingblanket or gowns, between the patient and thepressure-reducing surface; (4) operative timegreater than 90 to 120 minutes without reposi-tioning the patient; (5) moist skin from prepara-tive solutions or irrigation; and (6) shear and fric-tion on the operating table or during transfer.22

SPECIFIC POSITIONS

SupineEighty percent of surgical procedures take

place in the supine position.24 The hemodynamiceffects in a patient who is awake lying supine in-clude increased venous return with a compensa-tory decrease in cardiac contractility to limit theresulting increased cardiac output and hyperten-sion. In anesthetized patients, these mechanismsare perturbed. The sympatholytic effects of manygeneral anesthetics may necessitate the adminis-tration of additional fluids, sympathomimetics, orother vasopressors. The respiratory effects of lyingsupine include a decrease in total lung capacityand functional residual capacity, and a ventila-tion/perfusion mismatch. These effects are exac-erbated by the diaphragmatic paralysis of generalanesthesia and may worsen the hypoventilation ofa patient with chronic obstructive pulmonary dis-ease. Lastly, the two most common postoperativeneuropathies, ulnar and brachial plexopathy, oc-curring respectively in 28 and 20 percent of closedclaims in 1999, result from improper positioningand padding.24 This may be avoided by abductingthe arms no more than 60 to 90 degrees to avoidtraction on the brachial plexus, maintaining su-pination when the arms are abducted to avoid

pressure on the ulnar nerve as it passes posteriorto the medial epicondyle, maintaining a neutralposition when the arms are tucked at the patient’sside, properly padding the arm board, and notallowing the surgeon to lean on the extremities(Fig. 4).25

ProneProne positioning is the second most common

position in plastic surgery. Complications relatedto prone positioning include vertebral artery oc-clusion causing stroke, brachioplexopathy, andshoulder impingement causing pain.26 Most com-plications reported in prone surgery are related toexcessive pressure on the head and neck.27,28 Arare complication associated with prone position-ing is blindness; however, the etiology is multifac-torial and not just secondary to increased intra-ocular pressure.29 More commonly, it is secondaryto ischemic optic neuropathy, which too has manyetiologies.30 However, because proper positioningis an easy modifiable risk factor, it should be im-plemented with every case. A well-padded head-rest should always be used. Particular attentionshould be paid to eye protection and access to thepatient’s airway. The neck should be stabilized ina neutral, nonextended position, with neck rota-tion and accelerated movements avoided to pre-vent dissection of the carotid and/or vertebro-basilar arterial systems. Bilateral chest rolls shouldsupport the patient’s weight on the clavicles andiliac crests to lessen compressive forces on theabdomen and thorax, which may negatively affectcardiopulmonary status.29 The legs should be sup-ported on pillows from ankle to knee. The breastsand male genitalia should be padded. The turnfrom supine to prone of an anesthetized patient isthe most risky aspect of this position, and careshould be employed (Fig. 4).25

LithotomyThis position poses the same risks of upper-

extremity neuropathy, hemodynamic, and respi-ratory consequences as the supine position. Inaddition, there are significant consequences oflower-extremity venous stasis and hazards to lower-extremity peripheral nerves. The hips should bemaintained with minimal external rotation andthigh flexion, the lithotomy poles should be pad-ded to avoid compression of the common per-oneal nerve, and all maneuvers should occur si-multaneously with both left and right legs to avoidlumbar spine torsion (Fig. 4).25

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Fig. 4. Safety considerations of four common surgical positions. Reprinted with permission from Millsaps CC. Pay attention topatient positioning! RN. 2006;69:59 – 63.

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Lateral DecubitusAn axillary roll for the dependent axilla is

needed, as are pillows between the arms and legs.The lower leg should be flexed at the hip andknee, and the upper leg should be extended.There is a risk of compressive neuropathy of thebrachial plexus in this position, which may bereduced with a properly placed axillary roll. Thereis also a risk of traction on the suprascapular nerve,resulting in postoperative pain. The ear shouldnot be folded against its support. Lastly, there is apotential for thrombosis of the retinal artery of thedependent eye if it is compressed by the headrestor pillow (Fig. 4).25,31

SURGICAL SCRUB AND SKINPREPARATIONS

With regard to surgical preparations and bar-riers, two separate and complementary goalsshould be considered. The first is to minimize risksto the patient, such as surgical-site infection, caus-tic exposure, and thermal injury. The second is tominimize the hazards facing the surgeon and op-erating room staff, such as exposure to pathogensor chemicals. Much of our common surgical prac-tice has shown little evidence that it helps toachieve these goals.

The aim of hand antisepsis is to eliminate tran-sient bacteria and reduce commensulates, with theassumption that lower bacterial counts will reduceinfections.32 Modern research has tried to identifythe simplest effective method, but the wide variety oftechniques and underpowered studies make gener-alization difficult. Nevertheless, recent data havesupported that rubbing with an alcohol-based so-lution (e.g., Avagard; 3M, St. Paul, Minn.) is likelymore effective than scrubbing.32 Although scrub-bing eliminates transient bacteria, it uncoverscommensulates from the stratum corneum. Fur-thermore, repeated scrubs can cause excoriationand increased colonization with otherwise tran-sient bacteria.32

The antiseptic chosen to cleanse the patientshould act quickly, have a broad antibacterial spec-trum, and have some residual activity. Commonagents include various alcohols, iodinated prepa-rations, and chlorhexidine gluconate. An excel-lent combination of agents is alcohol, which worksimmediately, combined with chlorhexidine, whichprovides residual activity once the alcohol has evap-orated. A study by Darouiche et al. compared sur-gical-site infection in patients undergoing cleancontaminated surgery whose skin was cleanedwith chlorhexidine–alcohol or providine–io-

dine scrub and paint. They found the overallrate of surgical-site infection was significantlylower in the chlorhexidine–alcohol group.33

Rings should not be worn in the operatingroom by the surgeon, as they have been shown toincrease bacterial counts in the underlying skin.34

The organisms may not be easily removed withgeneral hand hygiene, and there is at least onecase report of cardiothoracic wound infectionsbeing traced to the rings of a staff surgeon, despitea full surgical scrub and gloves.35 Similarly, falsenails can increase colony counts. No clear dataexist for nail polish.36

As was the case with hand scrubs, preparationof the patient’s skin is meant to remove soil andtransient organisms, reducing infections. Themost common antiseptics are iodophors, alcohols,and chlorhexidine. Similarly to hand scrubs, theresearch regarding the ideal preparation does notexist.37 A simple shower with soap and water, witha preoperative saline rinse, may be sufficient toreduce the incidence of wound infection in cleancases.38 The traditional iodine soap scrub followedby paint may be unnecessary, particularly whenviewed in the context of data demonstrating thatscrubbing may excoriate the skin, exposing com-mensulates. Furthermore, iodine must dry to havefull effect, and it is often wiped off before startingthe case. Alcohol-based scrubs are immediatelyeffective at reducing colony counts.39 The benefitof incise drapes, such as OpSite (Smith & Nephew,London, United Kingdom) or Ioban (3M) has notbeen demonstrated, but the concept deservesstudy.40

Until clear data are available regarding skinpreparation solutions, we recommend using al-cohol-based preparations combined with eitheriodophore (DuraPrep; 3M) or chlorhexadine(Chloraprep; CareFusion, San Diego, Calif.) andfollowing the recommendations of the Centers forDisease Control and the Association of periOp-erative Registered Nurses.41 These recommenda-tions include the following:

1. Avoid shaving hair at surgical sites. If neces-sary, use a depilatory agent or clippers im-mediately before the procedure, away fromthe operative field.

2. Clean skin with a shower or surgical washbefore using an antiseptic preparation.

3. Prepare the surrounding skin and surgicalsites using an antiseptic.

4. Avoid pooling of the antiseptic beneath pa-tients, around cuffs or tourniquets or elec-trodes, and before using electrocautery; in

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addition, allow alcohol-based preparationsto dry thoroughly to prevent operating roomfires.

5. Annually, review policy regarding skinpreparations.

The data regarding the proper use of surgicalgloves are ambiguous. A recent Cochrane reviewby Tanner and Parkinson, however, suggests thatdouble gloving with indicator undergloves re-duces the incidence of perforation of the inner-most glove and increases detection of outer gloveperforations.42 Whether increased detection willlead to fewer blood-borne transmissions or surgi-cal-site infections remains to be seen.

Other barriers between the patient and oper-ating room staff include surgical clothing, masks,gowns, and drapes. Clothes and shoes dedicated tothe operating room are meant to reduce rates ofinfection; however, there is no clear evidence thatthey are successful. Many institutions now allowstaff to launder their scrubs at home, and theCenters for Disease Control consider the risk ofblood-borne pathogen exposure on soiled linen tobe negligible. The benefits of surgical masks inreducing rates of surgical-site infections are sim-ilarly dubious.43,44 Masks do, however, help pre-vent contamination to the surgeon.45 Also, therehas been no reliable relationship found betweengown and drape characteristics and surgical-siteinfection rates; therefore, recommendations re-main indistinct.45

CONCLUSIONSThe topic of patient safety in the perioperative

period is vast. Given the scope of the problem, anexhaustive review of all aspects of patient safetyrelated to inpatient plastic surgery could not becontained in a single issue of Plastic and Recon-structive Surgery; however, this article should stim-ulate all plastic surgeons to be vigilant in assessingtheir practice to improve patient safety.

Samuel O. Poore, M.D., Ph.D.University of Wisconsin Department of Surgery

Division of Plastic and Reconstructive Surgery600 Highland Avenue, CSC G5/361

Madison, Wis. 53792-3236poore@surgery.wisc.edu

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22. Armstrong D, Bortz P. An integrative review of pressure reliefin surgical patients. AORN J. 2001;73:645–648, 650–653,656–657 passim.

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23. Aronovitch SA. Intraoperatively acquired pressure ulcerprevalence: A national study. J Wound Ostomy Continence Nurs.1999;26:130–136.

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27. Sys J, Michielsen J, Mertens E, Verstreken J, Tassignon MJ.Central retinal artery occlusion after spinal surgery. Eur SpineJ. 1996;5:74–75.

28. Wolfe SW, Lospinuso MF, Burke SW. Unilateral blindness asa complication of patient positioning for spinal surgery: Acase report. Spine 1992;17:600–605.

29. Grant GP, Szirth BC, Bennett H, et al. Effects of prone andreverse trendelenburg positioning on ocular parameters.Anesthesiology. 2010;112:57–65.

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34. Kelsall NK, Griggs RK, Bowker KE, Bannister GC. Shouldfinger rings be removed prior to scrubbing for theatre?J Hosp Infect. 2006;62:450–452.

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37. Edwards PS, Lipp A, Holmes A. Preoperative skin antisepticsfor preventing surgical wound infections after clean surgery.Cochrane Database Syst Rev. 2004;3:CD003949.

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40. Shestak KC, Askari M. A simple barrier drape for breastimplant placement. Plast Reconstr Surg. 2006;117:1722–1723.

41. Centers for Disease Control. Guideline for prevention ofsurgical site infection, 1999. Available at: http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html. Accessed Septem-ber 18, 2007.

42. Tanner J, Parkinson H. Double gloving to reduce surgicalcross-infection. Cochrane Database Syst Rev. 2006;3:CD003087.

43. Lipp A, Edwards P. Disposable surgical face masks for pre-venting surgical wound infection in clean surgery. CochraneDatabase Syst Rev. 2002;1:CD002929.

44. Belkin NL. Home laundering of soiled surgical scrubs: Sur-gical site infections and the home environment. Am J InfectControl 2001;29:58–64.

45. Belkin NL. Masks, barriers, laundering, and gloving: Whereis the evidence? AORN J. 2006;84:655–657, 660–664.

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