Positioning Pitfalls to Avoid

Publish Date: March 14, 2018

The ideal scenario for the safest, most efficient and most effective patient positioning is early planning and risk assessment long before the patient arrives for surgery. Unfortunately, this is not universally practiced.

Too often, a perioperative nurse does not see the patient until the preop holding area or even upon arriving in the OR. If the patient is overweight with a high body mass index (BMI) that was not planned for or has other unknown positioning risk factors, the chances for the patient to experience a positioning injury increases dramatically, notes Carol A. Devlin, BSN, RN, RNFA, CNOR, an adjunct faculty member at Thomas Jefferson University College of Nursing in Philadelphia, Penn.

Perioperative team members are also at risk if there are not enough staff members and the correct transport devices to safely move a patient, Devlin says. “Time constraint is often an issue leading perioperative team members to transport a patient to the OR bed without protective strategies in place, even if a transport device such as a hover mat is available in the unit. This puts the patient at risk and can lead to career-ending injuries for the staff caused by a major injury or, more often, by a multitude of small injuries creating microtears in the soft tissues that support the spine.”

Pitfalls to Avoid

Devlin believes knowledge in evidence-based practices for safe positioning, including the basics such as the physiologic and anatomical impacts of anesthesia and intraoperative positioning, are critical to understand. She also believes it’s important for nurses to speak up and be proactive in addressing potential barriers to safe patient positioning.

Here are five of the most common positioning pitfalls Devlin sees nurses face:

  1. Not Planning Ahead for Patients with High BMI

    “Patients are getting larger and have comorbidities that require special precautions to protect vital areas with padding and correct positioning devices to prevent injury,” she says, giving the example of an obese patient undergoing shoulder surgery who is placed in the beach chair position. “The patient’s opposite arm must be placed on the arm board safely and protruding skin must be padded correctly to avoid injury from the board edge, post and clamps at the table edge.” Also, changing the position of the patient from supine to sitting may affect vital signs and must be done in a cautious, coordinated manner.

  2. Not Having Safe Staffing Numbers in the OR

    Ideally, each person should be responsible for 35lbs and use assistive devices. For a dependent patient who is sedated or unable to move, a minimum of four people is required for safe transport and repositioning the core of the body, according to Devlin. This is a particular concern with obese patients but is a safety risk when transporting any patient to the OR table because patients can develop skin injury if they slide along the OR supportive surface, rather than being properly lifted onto the surface.

  3. Not Being Prepared for New and Complex Procedures

    With technologies such as robotics for minimally invasive surgery and new approaches to procedures such as better access for orthopedic surgeries, patients are being placed in new positions that present unique challenges for safe positioning, Devlin explains. “Duration of the anesthetic and surgery are also a concern. If a new procedure is taking longer than expected, intraoperative monitoring by the perioperative nurse is key to addressing potential positioning injuries as soon as possible.”

  4. Not Being Comfortable Using Positioning Devices

    Developments in positioning support devices are also evolving from makeshift pillows and tape to the foam, gel pad overlays, and devices such as neurophysiologic monitors available today, Devlin shares. She cautions that nurses who aren’t familiar and comfortable using these devices are less likely to implement them safely or at all. “That’s why it’s so important to have adequate staffing in the room with each member of the team knowledgeable on unique positioning risks associated with the patient and the procedure.”

Solutions for Safety

While not every facility has the funds for cutting edge transport and positioning support devices, Devlin believes all perioperative nurses have the power to speak up for safe positioning. They can do this in several important ways:

  • Knowledge—Maintain competence in evidence-based positioning practices and safe use of positioning devices. If you work with colleagues who aren’t implementing the safest positioning approach, speak up with a safer alternative.
  • Standardized Assessment—Plan ahead as a team by accessing pertinent patient information at the start of the shift for scheduled cases. This planning is critical in using available devices, saving time, maintaining a flow of care, decreasing costs and most importantly, ensuring patient safety.
  • Awareness—Be watchful for patient skin condition prior to, during and after a perioperative procedure can lead to prevention or early detection of pressure injury. This awareness extends through recovery and can be optimized with good communication between the surgeon and other professionals working with the patient beyond the surgical setting. Bringing any findings back to the operating room is vital to learn from and better serve the next patient.


Devlin will be sharing more pearls of wisdom on preventing positioning pitfalls with her colleague Heidi Nanavati, MSN, CRNP, CNOR, in their education sessions on March 27 and 28 at AORN’s upcoming Global Surgical Conference & Expo in New Orleans.


Check out AORN’s Tool Kit for Prevention of Perioperative Pressure Injury with assessment resources and other evidence-based tools based on AORN’s Guideline for Positioning the Patient.


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