Can You Pass This Safety Quiz?

From pressure injuries to wrong-site surgery, our experts look to stump seasoned surgical leaders.

Patient and staff safety are obvious core values of every surgical organization. Yet problems in this realm are ever-present, and less-than-stellar outcomes continue — sometimes despite decades of warnings and guidance that could help. Policies must be implemented, reviewed and refined on an ongoing basis, because all perioperative team members are human and mistakes are always possible. We’ve asked some of the nation’s top experts for their input on several key safety topics. Take the following quiz to see how your facility measures up in these critical areas.

1. Which of the following are essential elements of a proper preoperative baseline skin assessment?

• a. A focused assessment on the area of the surgical incision.
• b. Applying prophylactic dressings on areas of high risk/pressure points.
• c. Allow patient to sit in chair or walk around the unit instead of laying on the gurney.
• d. Documenting observations.
• e. Repositioning q 30 minutes.
• f. Relieving all pressure from identified red areas/pressure points and from expected sustained surgical position.
• g. Consider use of subepidermal moisture monitoring for baseline on skin assessment.
• Reveal

  • Answer(s): b, c, e, f and g
    Choices a and d are lacking crucial information and action items that prevent them from qualifying as essential elements of a proper assessment. For instance, a focused assessment on the area of the surgical incision is far too narrow and fails to account for the broad thinking required of an OR staff that is proactively looking for areas on the patient where a pressure injury is likely to be sustained, says Cassendra Munro, PhD, RN, RNFA, CNOR, creator of the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients (Munro Scale) and the owner of Munro Consulting. Dr. Munro also points out that a proper, effective skin assessment includes the “four eyes” component. “The skin assessment really requires two nurses to inspect, agree and document that dual assessment,” she says. “A lot of institutions are now insisting on documenting dual assessments when it comes to the skin, and that’s a good thing. Even if it’s a two-hour procedure, we must perform another inspection with two RNs so that we identify that change from baseline and continue those preventative measures.”
    As for choice D, while documenting observations is indeed part of a proper assessment, it’s missing a key concept that would allow it to stand on its own as an essential element. “Documenting and communicating observations must go together,” says Dr. Munro, who adds that communication issues are at the heart of many pressure injury prevention problems. “It’s one thing that’s not as appreciated as it needs to be, those conversations between pre-op and intraop and then between intraop and post-op, because we’ve become so task-oriented, and there’s tremendous pressure on maintaining a timely schedule,” she says. “But we can start to have these conversations, to educate and inform the pre-op nurses and say, ‘During surgery, the patient will be in this position, and I’m concerned about those areas. Thank you for showing me your assessment and adding the prophylactic dressings.’” A similar conversation should occur with the post-op and inpatient nurse. Finally, Dr. Munro stresses the importance of ensuring OR teams are using a quality product that allows them to visualize and inspect underneath the dressing. “There are inferior products that do not allow removal for visual inspection and placement again,” she says. “Sometimes these products are rolling underneath the patient.”
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2. How many U.S. states have enacted surgical smoke evacuation legislation?

• a. 9
• b. 13
• c. 17
• d. 24
• e. 35
• Reveal

  • Answer: b
    A baker’s dozen may not sound like many, but at the beginning of 2021 only two states had enacted legislation mandating the use of smoke evacuation systems in every OR for every smoke-producing procedure. The addition of 11 more states over the last two years is a testament to the huge impact that concerned perioperative nurses and other staff are making — buttressed by a strong educational and advocacy push from members of the Association of periOperative Registered Nurses (AORN) — in statehouses across the country.
    The 13 states that have enacted surgical smoke evacuation legislation are Arizona, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, New Jersey, New York, Ohio, Oregon, Rhode Island and Washington. However, bills are pending this year in eight additional states: California, Florida, Massachusetts, Missouri, Pennsylvania, North Carolina, Texas and West Virginia. AORN Associate Director of Government Affairs Jennifer Pennock — who has worked tirelessly to get smoke evacuation bills over the finish line in every state — expects one or more of the nine states where legislation is pending to pass laws in July.
    Why all of this effort? Simply put, inhaling surgical smoke, which is full of toxic materials, is dangerous to OR staff and patients and can produce long-term health problems, including respiratory issues. The good news? The voices of everyone who works at surgical facilities are being heard — and if you work in a state that still hasn’t passed a surgical smoke evacuation bill, you can help make a difference.
    “We know that surgical smoke poses health risks to everyone in the operating room,” says AORN CEO and Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN. “For years, AORN has worked on the issue of surgical smoke at the policy and facility levels. AORN members across the country are working to enact state laws to ensure harmful surgical smoke is evacuated from every operating room to protect their health and safety. Through AORN’s Go Clear Program, nearly 300 facilities nationwide have gone surgical smoke-free. I urge AORN members to focus on this issue locally. Get involved in AORN’s advocacy efforts to go surgical smoke-free. Join the hundreds of facilities nationwide working toward their own Go Clear Awards.”
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3. According to joint recommendations from the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF), how long after a patient’s COVID-19 infection should anesthesiologists and surgeons/proceduralists wait to conduct a risk assessment regarding their suitability for elective surgery?

• a. 10 days
• b. Two weeks
• c. Two to seven weeks
• d. Seven weeks
• e. There is no longer a need for a waiting period
• Reveal
  • Answer: c
    Last month, ASA and APSF released updated recommendations regarding the timing of risk assessments to determine whether it is safe for patients who have suffered a COVID infection to undergo elective surgery and anesthesia. Their previously updated recommendations in the wake of the initial Omicron wave in early 2022 recommended a seven-week wait after the infection. Now the recommendation has changed to a rather broad time period: two to seven weeks.
    ASA President Michael W. Champeau, MD, FAAP, FASA, says the updates support and align with updated recommendations from Great Britain’s Association of Anaesthetists and Royal College of Anaesthetists, thanks to their analysis of data generated by the UK’s National Health Service — a centralized repository that is simply unavailable in the much more decentralized and privatized U.S. healthcare system.
    Dr. Champeau tells Outpatient Surgery Magazine that the combination of the current variant’s diminished ability to cause severe illness or death, combined with the fact that most Americans have either been vaccinated or already infected, caused the organizations to refresh their recommendations. “The disease has changed and become milder and, in general, people are more immunologically prepared or competent to fight it off,” he says.
    Still, the organizations emphasize that elective surgeries should not occur within two weeks of a COVID-19 infection. That gives anesthesiologists and surgeons enough time to both assess the patient’s risks and to reduce unnecessary risk of transmission to providers. The guidance notes that elective surgeries should be performed only after patients have clinically recovered from a COVID-19 infection and only when the anesthesiologist, surgeon or proceduralist and patient together agree to proceed.
    Risk assessment should include factors such as the patient’s age, the severity of the infection and surgical risk. If the patient and the surgery are determined to be low-risk, the anesthesiologist and surgeon should discuss scheduling with the patient. The decision to move forward also should account for whether the risk of proceeding exceeds the risk of delay, the organizations say.
    “Patients who have COVID-19-type symptoms should be screened and, if appropriate, tested before having an elective procedure,” they add. “Physicians should consider the timing and symptoms of the infection to determine when patients are no longer infectious.” To gather more relevant data going forward, the organizations recommend that facilities, surgeons and anesthesiologists track patient outcomes of elective surgery after COVID-19, including complications and mortality.
    Read the full updated joint recommendation statement at osmag.net/asacovid.
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4. During monopolar electrosurgery, a single-foil conductive return electrode is sufficient to engage the safety functions of a generator’s return electrode contact quality monitoring system (RECQM).

• a. True

• b. False

• Reveal
  • Answer: False
    If the team is using a conductive return electrode (versus a large capacitive gel pad), an RECQM requires a dual-foil — a.k.a. split foil — return electrode during monopolar electrosurgery, according to Julie Miller, MS, principal project engineer at ECRI, a non-profit organization in Plymouth Meeting, Pa., that provides independent medical device evaluation. Ms. Miller goes on to state that with a dual-foil electrode, the conductive surface is divided in two halves, with each half connected independently — via the same cable — to the electrosurgical unit (ESU). This split surface allows the ESU to sense impedance differences between the two halves of the conductive surface. (Note: Impedance is essentially the resistive element in a circuit with alternating current, as is the case with an ESU.)
    “The RECQM ceases ESU activation when the impedance is out of expected range or changes too much from its baseline value if the return electrode is not in good contact with the patient,” she says. “For example, if the patient is shifted during surgery and their return electrode peels away, an alarm will activate if the RECQM detects a large enough change in impedance between the two foils of the electrode. Clinical teams must address this issue before resuming the procedure.
    “This ultimately minimizes the risk of a return electrode patient burn. Note that a dual-foil conductive return electrode still requires appropriate sizing and placement depending on patient and procedure. Many general purpose ESUs do still accept single-foil return electrodes, which only engage a generator’s ‘continuity monitor’ — but this only alarms in the event that the return electrode or its cord is entirely disconnected.”
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5. The increase in minimally invasive procedures has resulted in a net reduction in incidences of unintentionally retained surgical items (URSIs) in recent years.

• a. True
• b. False
• Reveal

  • Answer: False
    Unintentionally retained items remain one of the most common sentinel events reported to The Joint Commission. While sponges used during open surgeries continue to be the most common item left behind, items such as needles, guidewires, device fragments, rectal tube caps and drain bulbs are also retained, many of them during minimally invasive surgery, according to the AORN guideline on the issue.
    Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CPPS, CJCP, the field director of The Joint Commission’s hospital/psychiatric hospital accreditation program, notes that while it’s encouraging that URSI reports to TJC have decreased since 2018, they’re still among the top-five of reported sentinel events — and are likely to be voluntarily reported as little as 2% of the time.
    “Even one URSI is too many,” says Dr. DiBlasi Moorehead.
    The causes of the incidents are usually multifactorial, and often include an inconsistent counting process used during a difficult procedure. Other variables can include a clinical change taking place during the procedure or when staff changes midway through a lengthy surgery.
    While facilities should certainly make sure they have a highly reliable, consistent manual counting process in place, AORN recommends the use of some form of adjunct technology such as radio-frequency detection or data matrix-coded systems to supplement an OR team’s count.
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6. Wrong-site errors are almost entirely preventable if protocols that include built-in redundancies are followed to the letter.

• a. True
• b. False
• Reveal

  • Answer: True
    Errors take place when airtight policies aren’t implemented in meaningful fashion, explains Carlos Pellegrini, MD, FACS, the chair of The Joint Commission board of directors and past-president of the American College of Surgeons and the American Surgical Association.
    “Wrong-site errors are virtually entirely avoidable if facilities don’t spread themselves too thin or cut corners and implement protocols exactly as they are written,” says Dr. Pellegrini.
    It all starts with the culture of safety of the health system. One of its components is an effective time out. Dr. Pellegrini notes there are abundant resources available from The Joint Commission and the World Health Organization to make sure yours is a good one.
    The Joint Commission even offers a tool that allows facilities to customize their time outs, as well as identify issues that could make a particular facility potentially vulnerable to a wrong-site event.
    Similarly, it’s not enough to assume your OR team members feel free to say something when they are concerned. To truly transform a perioperative speak-up culture from a mission statement to a reality, each team member must feel like they are part-owner in every procedure and that their participation is vital. They should not simply feel as though they’re allowed to announce when they see something might be awry, they should be obligated to do so.
    “That’s when you truly have flattened the hierarchies,” says Dr. Pellegrini.
    Distractions such as small talk about things other than the case at hand should be eliminated, he suggests, and surgeons must always communicate when they are diverting from a procedure’s normal plan of operations. Acknowledging that everyone could make these kinds of mistakes is a good first step toward building in an abundance of safeguards that are available. OSM
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