The

Aligning practice with policy to improve patient care

Volume 3, Issue 2

How to Thrive in
Back to Basics: a Tough Economy
Electrosurgery

Surgical Site Infections:

Are you playing your
part in prevention?
5 Pressure
Ulcer
Factors
to Keep
FREE CE PAGE 22 in Mind
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 The

OR Connection
Aligning practice with policy to improve patient care

Sue MacInnes, RD, LD

Editor
PATIENT SAFETY
16 Back to Basics: Electrocautery Safety and OR Fire Prevention
Alecia Cooper, RN, BS, MBA, CNOR
Clinical Editor

24 Left Behind
Andy J. Mills, MBA, MWM
Contributing Editor
30 World Health Organization Issues Safety Checklist for
Surgical Teams
Mike Gotti
Art Director
37 Surgical Site Infections
Laura Kuhn
Copy Editor
43 Flipping the Switch on Pressure
46 Five Pressure Ulcer Factors to Keep in Mind Page 13

Jayne Barkman, RN, BSN, CNOR

Clinical Team

Rhonda J. Frick, RN, CNOR OR ISSUES

Anita Gill, RN 40 Great Ideas from Your Peers: Surgical Skin Prep Solutions
Megan Giovinco, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse 50 The History of the Surgical Technologist
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSN SPECIAL FEATURES
Connie Sackett, RN, Nurse Consultant 5 Letters from Our Readers
Claudia Sanders, RN, CFA
Angel Trichak, RN, BSN, CNOR
13 SCIP’s Role in the CMS 9th Scope of Work Proposal Page 16

32 Moments of Truth
Gail Avigne, RN
Perioperative Advisory Board
54 A Place of Healing?
Shands Teaching Hospital (UFL), Florida
Caroline Copeland, RN MPH
58 Callie Craig: A Nurse Hero
Southern Hills Hospital & Medical Center 62 How to Thrive in a Tough Economy
Cathy Crandall, RN
HealthTrust Purchasing Organization, Tennessee
68 Angel’s Passion for Pink
Larry Creech, RN, MBA, CDT
71 Medline Supports Breast Cancer Awareness
Carilion Health System, Virginia 73 Recipe: Guacamole Page 24
Pat DʼErrico, RN, CNOR
Medical Center of Central Georgia, Georgia CARING FOR YOURSELF
Barbara Fahey, RN CNOR
Cleveland Clinic, Ohio
61 Building Unshakable Self-Confidence
Zaida Jacoby, RN, MA, M.Ed 72 Ease the Discomfort of PMS
NYU Medical Center, New York
Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA FORMS & TOOLS
Wellstar Kennestone Hospital, Georgia 76 Electrosurgery Checklist
Wayne Malone, RN
Physicians Hospital, Texas
78 Electrosurgical Cautery Safety Page 32

Lynda Mansfield, RN, CNOR 81 Pressure Ulcer Prevention

Orange County Memorial, California
86 Surgical Safety Checklist
Jackie Minor, RN CNOR
Huntsville Hospital, Alabama
89 Checklist: Organizational Assessment Questions Regarding
Jennifer Misajet, BSN, MHA, CNOR Management Commitment to Employee Involvement
Exempla St. Joseph Hospital, Colorado
90 Confidential Incident Report
Pricilla Ranseur, RN, MSN, CNOR
Duke University Hospital, North Carolina
Margie Voyles, RN, MS, CNOR
Lakeland Regional Medical Center, Florida
Page 62

Margery Woll, RN, MSN, CNOR

Rush North Shore, Illinois

Aligning practice with policy to improve patient care 3

 THE OR CONNECTION I Letter from the Editor

Dear Reader,
Everyone agrees that preventing hospital-
acquired conditions can save thousands of lives
and millions of dollars. This is the time to take
action. Hospitals across the country are implement-
ing new strategies. All of us are feeling the swell of
change and the push back that comes with it.
Whether you are working with administration, mate-
rials management, your staff, physicians, vendors,
consultants or your peers, the journey isnʼt and wonʼt
be easy. Iʼve spoken to thousands of clinicians about
the barriers they are facing when it comes to imple-
menting new policies and improving safety, quality
and patient satisfaction. Everyone wants to do
whatʼs right. The overwhelming things that we need
to make that happen are teamwork, communication,
education and – in many cases – additional
resources.
This edition of The OR Connection is about bringing
positive change into your facility. One key solution
Then go to Page 86 in the Forms & Tools section,
where you can tear out a copy of the checklists for
your own use.
But even with your checklist in hand, it might not be
enough. That is why you should read through
“Moments of Truth: How to enact a culture change at
your facility.” There are no miracles here, but a keen
understanding and expert guidance on how to create
a team that works together, problem-solves together,
helps each other out to give the patient the best
care possible.
Each of us contributes to the culture we work in, so
I was thrilled with Wolfe Rinkeʼs article “How to
Thrive in A Tough Economy” (Page 62). This article
“
This edition of
The OR Connection
takes a closer look at how you can positively affect
is about bringing
your organization and your career in these times. positive change
Last, but certainly not least, this edition is chock-full
into your facility.”

that can help your patients receive a higher standard of safety updates and information. Thank you for
of care is the use of a checklist. I know if something being a part of the team. We look forward to visiting
is not on my list, there is a chance it will be forgotten. with you again in our next edition.
With the day-to-day pressure, interruptions and
stress that each of you must deal with in the OR, a Sincerely,
checklist might be just the right calming factor.
Checklists act as reminders to keep us on track, to
make sure weʼve covered everything we need to do. Sue MacInnes, RD, LD
Youʼll want to take a look at Page 30, where you will Editor
find the “Safety Checklist for Surgical Teams.” There
are three recommended checklists:

1. Before anesthesia is induced

2. Before skin incision
3. Before the patient leaves the operating room

We've coded the articles and information in this magazine to indicate which patient
Content Key

care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 2007 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the above
initiatives, see pages 6 and 7.

4 The OR Connection

Letters from Our Readers
I really enjoy The OR Connection and find the articles to be
interesting, current and evidence-based. I look forward to the
new issues and have been able to implement some of the
tools as teaching aids. Thank you very much for a publication
specifically for the OR which puts policy and practice together
to improve patient care and safety.
– Maureen Bollin, RN, CNOR, Perioperative Educator
As an educator, I was pleased with the timeliness of the
articles, the activities for the staff and their presentation. The
topics are pertinent, and easy to read. I love the variety to
articles. I am only sorry I don't have all your issues. This
magazine is a great resource tool, and when your staff needs
an in-service, there is always something to draw on. Thank
you for publishing it, I hope it continues.
– K. Smith
This type of project is so very valuable to clinicians and
establishes your clinical credibility that is a major differentiator in
the market today. Kudos to you and to your clinical team.
– Sandy Wise, RN, MBA
I received this issue at AORN Congress this year in
Orlando. What a GREAT magazine this is!!! It incorporates
so many of today's issues affecting perioperative care. The
education is invaluable. Thank you!
– Rose Trojkovich
I recently got to read Volume 2, Issue 1 given to me by a
fellow OR nurse and I really enjoyed the great reading and
love the format. I plan on using this info in education of the OR
staff in my facility. As an educator I am always looking for
Aligning practice with policy to improve patient care 5
You Said It!
fresh ideas and articles to share with my staff that is relevant
and easy to understand. I just signed up for a subscription for
our OR dept and want to thank you. I think the crosswords
and word search are fun and informative.
– Sara Smith, RN, CNOR
I wanted to pass along a thank you for The OR Connection
magazine you dropped off. I really enjoy reading them. There
is a lot of valuable information in it that I pass along to others.
I get a lot of magazines in the mail and I must say this is one
of the few I review cover to cover and pass on to others.
Medline does a nice job with this. Thanks again!
– Janna Petersen, RN
I love your magazine, keep up the good work!
– Lynne Arnaut
The Back to Basics series has become a hit at our two
facilities….I had been working hard on getting staff to read
your great issues of The OR Connection and now it looks
like it has finally happened.
– Sophia Schild
Great issue of The OR Connection! I am just amazed at the
content, information, format, etc. You do have a gift for this
publication series.
– Nancy B. Bjerke, RN, MPH, CIC
Has The OR Connection been helpful at your facility? Is
there a topic youʼd love to see us tackle? Drop us a line at
orconnection@medline.com. Weʼd love to hear from you!
 Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.

1 5 Million Lives Campaign

Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006
Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires
additional monitoring, treatment or hospitalization, or that results in death
Goal: To prevent five million incidents of medical harm over the next two years and to enroll more than
4,000 hospitals and their communities in the project.

Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides
and tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.

2 Joint Commission 2008 National Patient Safety Goals

Origin: Developed by Joint Commission staff and a Sentinel Event Advisory Group
Purpose: To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission
offers guidance to help organizations meet goal requirements.

This yearʼs new requirements have a one-year phase-in period that includes defined expectations for planning,
development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation
by January 2009.

3 Surgical Care Improvement Project (SCIP)

Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in four target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.

6 The OR Connection
 Patient Safety

5 Million Lives Campaign: Twelve Interventions

1. Prevent pressure ulcers
2. Reduce methicillin-resistant staphylococcus
aureus (MRSA) infection
3. Prevent harm from high-alert medications
4. Reduce surgical complications
5. Deliver evidence-based care for congestive heart failure
6. Get boards on board
7. Deploy rapid response teams
8. Prevent adverse drug events (ADEs)
• An IHI forum, “Celebrating 20 Years: The Future
of Health Care is Ours to Imagine,” will be held in
Nashville December 8-11, 2008
• For the latest on patient safety, visit
UPDATE
http://www.ihi.org/IHI/Topics/PatientSafety/
9. Deliver evidence–based care for acute
myocardial infarction
10.Prevent surgical-site infections
11. Prevent central-line infections
12.Prevent ventilator-associated pneumonia
By the numbers:
• 3,954 hospitals currently enrolled
• The Top 3 Interventions:
1. Adverse Drug Events (ADEs) – 3,010
2. Surgical Site Infection (SSI) – 2,923
3. Acute Myocardial Infarction (AMI) – 2,893
To learn more, visit www.ihi.org

Joint Commission 2008 National Patient Safety Goals

• Improve accuracy of patient identification
UPDATE • Improve effectiveness of communication
among caregivers
• Improve medication safety
• Reduce risk of healthcare-associated infections
(Expanded in 2008 to include either WHO
or CDC Hand Hygiene Guidelines)
• Reduce risk of patient harm from falls
• Reduce risk of influenza and pneumoccocal
disease through immunization
• Reduce risk of surgical fires
• Encourage patientʼs active involvement in their care
• Prevent healthcare-associated pressure ulcers
(decubitus ulcers)
• Identify safety risks inherent in patient population
(suicide, home fires)
• Rapid response to changes in patient condition
(new for 2008)
• Implementation of Universal Protocol for preventing
wrong-site, wrong-person, wrong-procedure surgery

To learn more about the proposed 2009 National Patient Safety Goals, go to www.jointcommission.org and see the News Flash on Page
8 of this issue.

Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical-site infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, normothermia
• 3,740 hospitals are submitting
2. Perioperative cardiac events data on SCIP measures, representing
• Use of perioperative beta-blockers 75 percent of all U.S. hospitals
3. Venous thromboembolism • Currently, SCIP has more than 36
• Use of appropriate prophylaxis association and business partners

CMSʼs 9th Scope of Work is available at cms.hhs.gov/QualityIMprovement9thsow.asp#TopOfPage.

SCIP measures are included in the 9th Scope of work. The 9th Scope of Work began August 1,
2008 and runs for three years. To learn more, see the article on Page 13 of this issue.
UPDATE

To learn more, visit www.medqic.org/scip.

Aligning practice with policy to improve patient care 7

 News Flash
CMS Proposes Additions to List of Hospital-
Acquired Conditions for Fiscal Year 2009
On April 14, 2008, the Centers for Medicare & Medicaid Services
(CMS) announced a proposed rule that would update payment
policies and rates under the hospital inpatient prospective payment
system (IPPS) for fiscal year (FY) 2009, beginning for
discharges on or after October 1, 2008. CMS is proposing to
select nine categories of hospital-acquired conditions (HACs)
for FY 2009 in addition to the eight selected one year ago.
Candidate HACs for 2009
• Surgical site infections following specific elective procedures:
total knee replacement, laparoscopic gastric bypass and
gastroenterostomy, ligation and stripping of varicose veins
• Staphylococcus aureus septicemia
• Clostridium difficile-associated disease (CDAD)
• Ventilator-associated pneumonia (VAP)
• Deep vein thrombosis (DVT)/pulmonary embolism (PE)
• Legionnairesʼ disease
• Iatrogenic pneumothorax
• Delirium
• Extreme glycemic aberrancies
Joint Commission Announces
2009 National Patient Safety Goals
The Joint Commission has announced the 2009 National
Patient Safety Goals and related requirements for accredited
hospitals and critical access hospitals, accredited ambulatory
care facilities and offices in which surgery is performed.
In addition to the existing National Patient Safety Goals,
the following modifications and additions have been made:
New:
• “Eliminate transfusion errors related to patient
misidentification” was added to the “Improve accuracy
of patient identification” goal
• Accurately and completely reconcile medications across
the continuum of care.
• “Implement best practices for preventing surgical site
infections” was added to “Reduce the risk of health care
associated infections.”

The announcement of the additional conditions that are

selected will be made at the same time this magazine is going
to print. We encourage you to go to www.cms.gov to find out
which of the 9 candidate HACs were chosen. Look for
additional information on the HACs selected for 2009 in the
next issue of The OR Connection magazine.

The Results Are In!

Hereʼs what you had to say about The OR Connection

The staff of The OR Connection would like to thank the 582 of

you who took the time to complete our online readership survey!
Weʼve learned a lot from what you had to say, and we wanted to
share some of the results with you!

We learned that Patient Safety is the most-read section of the

magazine, followed closely by OR Issues. We were excited to
learn that 93 percent of you find the information in The OR
Connection to be useful.

We also learned a lot about your priorities. Eighty-eight percent of

you told us that patient safety is a priority, followed by turn-
around time (73 percent), surgical site infection prevention (69 per- Thanks again for your feedback – we look forward
cent), education (35 percent) and new innovation (22 percent). to continuing to hear from you in the future!

8 The OR Connection
 News Flash
APIC Announces New Name for Infection
Control Professionals
To articulate the expanding roles of its members, the
Association for Professionals in Infection Control and
Epidemiology (APIC) announced that infection control
professionals will now be referred to as “infection
preventionists.” This newly created term joins the list of
professional titles such as hospitalists, intensivists and
interventionists introduced by the healthcare industry over
the past several years.
Infection preventionists direct interventions that protect
patients from healthcare-associated infections (HAIs) in
clinical and other settings around the world. They work with
clinicians and administrators to improve patient and
systems-level outcomes and reduce HAIs and related
adverse events.
“The term infection preventionist clearly and effectively
communicates who our members are and what they do,”
said Kathy Warye, APICʼs CEO. “Infection preventionists
develop and direct performance improvement initiatives that
save lives and resources for healthcare facilities, so this
was a natural transition – or a right-sizing of the name – to
more accurately reflect their role. By creating a new word,
we hope to raise awareness about what infection preven-
tionists uniquely contribute to patient safety, improved out-
comes and bottom line savings to healthcare institutions.”
To view the complete press release, please visit
http://www.apic.org//AM/Template.cfm?Section=Home1.
Aligning practice with policy to improve patient care 9
Study: Time is of the Essence with
Postoperative Indwelling Catheter Use
A recent study found that surgical patients whose
indwelling catheters were left in place for more than
48 hours are twice as likely to develop a urinary tract
infection, resulting in increased length of stays, hospital-
ization costs and rehospitalizations.
The study, published in the June 2008 issue of Archives of
Surgery, is titled “Indwelling Urinary Catheter Use in the Post-
operative Period: Analysis of the National Surgical Infection
Prevention Project Data.” It was authored by Heidi Wald, MD,
MSPH; Allen Ma, PhD; Dale Bratzler, DO, MPH and Andrew M.
Kramer, MD.
Data used in the study was collected from nearly three
thousand U.S. acute care hospitals participating in the Surgical
Care Improvement Project. The study revealed that of the
surgical patients who had received indwelling catheters, half
had the catheters in place for more than two days. The group
whose catheters were left in for more then 48 hours was twice
as likely to develop a urinary tract infection.
The study clearly demonstrates that urinary catheters in post-
operative patients should be removed as soon as possible to
decrease the likelihood of an adverse outcome.
To learn more about the study, please visit http://archsurg.ama-
assn.org/cgi/content/short/143/6/551.
Now is the time.
This is the opportunity.

Medline presents a powerful and comprehensive The six conditions targeted by Prevention Above All
solution to six of the most common hospital-acquired and their complementary Medline product and program
conditions (HACs). solutions are:
• Wrong site surgery
Preventing HACs is one of the most important issues in Surgical Time Out Procedure Drape
health care today. Simply put, the CMS reimbursement • Hospital-acquired infections
changes taking effect October 1 mean healthcare pro- Hand Hygiene Compliance Program

fessionals must eliminate HACs and improve patient • Pressure ulcers

Pressure Ulcer Prevention Program
safety — or risk losing Medicare reimbursement dollars.
• Harm avoidance and patient satisfaction
Educational Packaging
The good news is that almost all HACs are preventable,
• Objects retained after surgery
and with Medline’s Prevention Above All, you will have RF Surgical Detection System™
the knowledge and products to prevent six of the most • Catheter-associated urinary tract infections
common HACs. The program’s multi-layered approach Silvertouch™ Catheter
provides you with targeted evidence-based interventions
that will not only save lives but also improve your To learn more about Prevention Above All,
bottom line. contact your Medline representative, call
1-800-MEDLINE or visit us at
www.medline.com/special/paa.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Special Invitational Forum
Medline presents an executive Prevention Above All forum focusing on
the implications of the new CMS guidelines, targeted interventions and
practical solutions.

Keynote speaker:
John Nance, JD
A founding member of the
National Patient Safety Foun-
dation and one of the foremost
thought leaders on change in
America’s healthcare system
and a regular contributor to
ABC World News and Good
Morning America, John is
also the author of 18 books,
including his latest, Why Hospitals Should Fly: The
Ultimate Flight Plan to Patient Safety and Quality Care.

Featured speakers:
Deborah Adler Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Senior designer at the design firm Milton Glaser, Inc. Board certified wound specialist with extensive experi-
and the inspiration behind Target’s ClearRx system ence in wound, ostomy & incontinence care.

Dr. Dale Bratzler, DO, MPH Heidi Wald, MD, MSPH

Medical Director of the Hospital Interventions Quality Im-
provement Organization Support Center and the Hospi-
tal Quality of Care Measures Special Study
Larry Creech, RN, MBA, CDT
Vice President Perioperative Surgical Services, Clarian
Health Partners
Dea Kent, RN, MSN, NP-C, CWOCN
Practicing nurse for 20 years and the manager and pri-
mary provider at the Wound Healing Center at St.
Joseph Hospital in Kokomo, Indiana
Dr. Andrew Kramer
Professor of Medicine, Head of Division of Healthcare
Policy and Research, University of Colorado
Assistant Professor of Medicine, University of Colorado
Kathy Warye
Chief Executive Officer of Association for Professionals in
Infection Control and Epidemiology (APIC)
For more conference information,
visit www.medline.com/special/paa.
• Learn about Prevention Above All
• Speaker biographies
• Select conference presentations (available 8/20)
• Request information on specific interventions
You have too much on your hands...
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

SCIP’s Role in the CMS 9th
Scope of Work Proposal
By Dale Bratzler, DO, MPH
Medical director, Hospital Interventions Quality
Improvement Organization Support Center and the
Hospital Quality of Care Measures Special Study
Aligning practice with policy to improve patient care 13
Special Feature
On August 1, the Centers for Medicare & Medicaid Services
launched its next three-year cycle of healthcare quality improvement
initiatives for Medicare providers, known as the 9th Scope of Work
(SoW). Under the direction of CMS, the Quality Improvement
Organization (QIO) Program consists of a national network of 53
QIOs responsible for each U.S. state, territory and the District of
Columbia. QIOs work with consumers and physicians, hospitals
and other caregivers to refine care delivery systems to make sure
patients get the right care at the right time, particularly patients
from underserved populations. The Program also investigates
beneficiary complaints about quality of care.
 The Patient Safety theme is designed to address areas of patient
harm by using established, evidence-based research that improves
healthcare processes and systems. Key areas of focus in the
Patient Safety theme include:
• Improve inpatient surgical safety and heart failure rates
(SCIP/HF)
• Decrease the rate of pressure ulcers
(PrU-Nursing Homes and Hospitals)
• Reduce the use of physical restraints (PR)
• Improve drug safety
• Reduce rates of healthcare associated
methicillin-resistant Staphylococcus aureus (MRSA)
• Providing quality improvement technical assistance
to nursing homes in need
The focus of the Surgical Care Improvement Project (SCIP) has
been the recruitment of hospitals for participation in the programʼs
process measurements. The measurements were defined and
recommended through evidenced-based practice to improve
outcomes of surgical patients.
The specific SCIP measures include:
Infection
• SCIP INF 1: Prophylactic antibiotic received within one hour
prior to surgical incision
• SCIP INF 2: Prophylactic antibiotic selection for surgical patients
• SCIP INF 3: Prophylactic antibiotics discontinued within 24
hours after surgery end time (48 hours for cardiac patients)
• SCIP INF 4: Cardiac surgery patients with controlled 6 a.m.
postoperative serum glucose
• SCIP INF 6: Surgery patients with appropriate hair removal
14 The OR Connection
Cardiac
• SCIP Card 2: Surgery patients on a beta-blocker prior to arrival
that received a beta-blocker during the perioperative period
Venous thromboembolism
• SCIP VTE 1: Surgery patients with recommended venous
thromboembolism prophylaxis ordered
• SCIP VTE 2: Surgery patients who received appropriate
venous thromboembolism prophylaxis within 24 hours prior
to surgery to 24 hours after surgery
Facilities participating in SCIP are collecting data and then
depositing the data in the CMS Clinical Data Warehouse
(CDW), a national repository from which hospital-specific
performance rates are derived for public reporting on
Hospital Compare. Additional information is available at:
www.cms.hhs.gov/QualityImprovementOrgs (click on “Statement
of Work”) and at www.medqic.org/scip.
About the Author
Dale Bratzler, DO, MPH, has been involved in healthcare quality
improvement on the local, state and national level since 1987.
Dr. Bratzler currently serves as the Medical Director for the
Hospital Interventions Quality Improvement Organization Support
Center and the Hospital Quality of Care Measures Special Study.
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Bovie is a registered trademark of Bovie Medical Corporation.
16 The OR Connection
 Eighth in a Series
Back to Basics
Electrocautery Safety and
OR Fire Prevention
By Alecia Cooper, RN, BS, MBA, CNOR
It could happen at any time, to anyone and when you
least expect it. If and when it does, your patient, you and your
coworkers could suffer serious injuries, depending upon the
extent and type of error.
The safe and proper use, maintenance and disposal of
electrocautery equipment in the operating room should never
be overlooked or taken too lightly. If you do, you could be
faced with one of the most terrifying experiences of your
professional career. Complications and patient injury due to
improper use of electrocautery devices include inadvertent
and advertent thermal injury, burn, fire, cardiac arrhythmias
and interference with pacemakers. Although all are serious
complications, a surgical fire can be the most critical.1
Two devastating cases
Following a successful gallbladder surgery at a metropolitan
medical center in Boston, a female patient experienced a flash
fire ignited on her midsection. The patientʼs abdomen was
cleansed following her surgical procedure with an alcohol-
based cleansing solution. The surgeon then decided to
remove a mole from the patientʼs abdominal area using
electrocautery. Blue flames immediately shot up from her
midsection – “similar to a flambé,” the surgeon told state
health investigators. The patient suffered painful first- and
second-degree burns.2
According to the ECRI Institute, 44 percent of operating room
fires occur during head, face, neck or chest surgery, when
electrical surgical tools are closest to the oxygen the patient
is breathing.2
Aligning practice with policy to improve patient care 17
Patient Safety
A 68-year-old man was scheduled for ambulatory surgery to
remove a skin lesion on his right cheek. A moderate amount
of bleeding was encountered during the punch biopsies and
an electrocautery device was used to cauterize the skin edges
– igniting the nasal cannula and surgical drapes surrounding
the face. The surgeon poured sterile water from the operative
tables on the patient and the nasal cannula to extinguish the
fire. The nasal cannula and drapes were removed from the
patient and thrown to the floor. The nasal cannula continued
to burn until anesthesia personnel turned the oxygen off. Once
the fire was extinguished, new instruments and drapes were
obtained. The patient was re-draped and the procedure was
completed. A thorough examination indicated first- and
second-degree burns involving both cheeks, as well as the
right nasal vestibule.3
The history of electrocautery
Cauterization began as a means to stop heavy bleeding,
especially during amputations. The procedure was simple: a
piece of metal was heated over fire and applied to the wound.
This would cause tissues and blood to heat rapidly to extreme
temperatures, causing coagulation of the blood and thus
controlling the bleeding. Next came medical instruments
called cauters, used to cauterize arteries.
Electrocauterization (also called electric surgery or electro-
surgery) is the process of destroying tissue with electricity. It
is widely used in many surgical procedures. The procedure is
most frequently used to stop the bleeding of small vessels or
for cutting through soft tissue. The electrocautery generator
(ESG), more commonly referred to as an electrosurgical unit
 (ESU) or simply as a generator, powers an electrosurgical
system with electricity at an appropriate voltage, frequency
and waveform for cutting or coagulation, as required.
Frequency
To prevent electric shock, an alternating frequency that is
higher than power from standard wall outlets is used. Normal
AC “house-current” runs at 50-60 Hz and is quite lethal, since
at every alternation nerves and muscles get stimulated, causing
violent cramps at 50 to 60 times per second. However, nerve
and muscle stimulation cease at 100,000 Hz, due to alterations
being too fast for the cells to pick up. Electrosurgery can be
performed safely at “radio” frequencies above 100 kHz.4
Cutting vs. coagulation
Different cauterizing effects can be achieved by changing the
voltage of the current as well as the pattern of electric pulses.
When lower voltage is used with a continuous alternating cur-
rent (AC), heat is produced very fast and tissue is completely
vaporized at the tip of the probe. The effect is “cutting.” When
a higher voltage current is used in a pulsed manner, heat is
produced more slowly, tissue damage is more widespread and
blood coagulates. In many electrosurgery instruments, this is
called “coagulation” mode. This is used for ablation. Usually a
“blend” setting is available as well.
Monopolar vs. bipolar
Both monopolar and bipolar electrocautery involve high-
frequency alternating current and a pair of electrodes, one
referred to as “active” and the other “returning.” The difference
lies in the placement of the electrodes.
18 The OR Connection
Monopolar
Current is passed from the active electrode, where cauterization
occurs, and the patientʼs body serves as a ground. A grounding
pad is placed on the patientʼs body, usually the thigh, and it
serves as the returning electrode, which carries the current
back to the machine. The placement of the return electrode is
critical in preventing extensive burns.
Bipolar
The active and receiving electrodes are both placed at the site
of cauterization. The probe is usually in the shape of forceps,
with each tine forming one electrode, cauterizing only the tis-
sue between the electrodes.
Probes
Different shapes of cautery probes are used for different
purposes. A common monopolar probe is pen-shaped but
ending in a small slender scalpel-shaped spatula of about 5 to
30 mm. This can be used a both a coagulator and an electric
scalpel. The typical bipolar probe resembles a pair of tweezers
that grasp and cauterize a small piece of tissue. There are
variations of these probes that can be used in both open and
minimally invasive surgical procedures.
The chance of fire
Electrosurgery electrodes and devices are frequently ignition
sources for surgical fires. These types of fires are a potentially
devastating yet preventable adverse event. Thankfully, fires
in the operating room are not frequent. According to ECRI,
only 50 to 100 surgical fires are reported each year – but the
fires can result in serious consequences to patients, damage
to equipment and interruptions to operations.5
According to one ECRI report, an electrosurgical pencil
caused a drape fire because it was not placed in a non-
conductive holster.6 In this incident, a pencil fell off the sterile
field, was not removed and instead was left dangling. A surgical
team member leaned against the pencil, causing it to activate,
arc through the drapes to an instrument table and ignite the
drapes. The flame spread rapidly up the drapes, vertically from
the point of ignition, about two feet off the floor, to the patient.
By this time, the fire was burning with such intensity that all
other flammable materials on and around the patient ignited
and quickly burned. This fire was fatal to the patient. Did you
know that that materials burn more quickly when vertical?
There are three conditions that must be in place for a fire to
occur: fuel, oxygen and heat. When brought together, these
components complete the fire triangle. Preventing a fire in the
OR can be achieved by controlling the elements that make up
the fire triangle.
Control ignition sources
The most common ignition sources in the OR are electrosur-
gical and/or electrocautery equipment and lasers. ECRI
reports that approximately 68 percent of surgical fires involve
electrosurgical equipment and 13 percent involve lasers. We
have control over ignition sources.6
ECRI recommends that during electrosurgery6:
• Remove unneeded foot switches to avoid
inadvertent activation.
• Place the electrosurgical pencil in its holster when
not in active use and place the electrosurgical unit in
the standby mode.
• Allow the tip of the pencil to be activated only by the
individual wielding it and when it is under direct
observation of the surgeon.
• Use only active electrode tips that are manufactured
with insulating sleeves.
• Do not use electrosurgery to enter the trachea.
• Do not use electrosurgery in close proximity to
combustible materials and oxygen-rich atmospheres.
• Dispose of electrocautery pencils properly. For
example, break off the cauterizing wire and cap
the pencil.
Control oxygen levels
We can control oxygen-rich environments in the OR, which in-
clude any atmosphere where there is greater than 21 percent
oxygen. While oxygen will not burn or explode, it can cause
materials that will not ignite or that burn slowly in ambient air
to easily ignite and burn rapidly. The vapor density of pure oxygen
(1.1) is slightly heavier than air. This means that pure oxygen
may collect in depressions or under drapes or clothing.
Aligning practice with policy to improve patient care 19
Nitrous oxide use can increase effective oxygen levels above
21 percent. Like oxygen, nitrous oxide also has a vapor
density greater than 1.0. With a vapor density of 1.53, it will
collect in low-lying areas as well.6
ECRI data shows that 74 percent of the reported surgical fires
occurred when oxygen levels were elevated above 21
percent. It's important to understand that oxygen may collect
and its concentration become elevated. This can occur under
surgical drapes, in clothing, on the surface of the skin due to
the presence of vellus (short, fine, "peach fuzz" body hair) and
around masks, tubes or nasal cannula when patients are pro-
vided oxygen or nitrous oxide from compressed gas cylinders
or piped medical gas systems.6
To control oxygen concentration levels
ECRI recommends6:
• That the requirement for 100 percent oxygen for
open delivery to the face (for example, when using
nasal cannula) be questioned if a lower concentration
is consistent with the patient needs.
• Stopping supplemental oxygen at least one minute
before using electrosurgery, electrocautery or laser
surgery on the head or neck.
• Titrating the delivery of oxygen to the patient based
on the patientʼs blood-oxygen saturation.
• Tenting drapes to allow gases to drain away from
the operating table.
• Using a properly applied incise drape, if possible,
to help isolate head and neck incisions from
oxygen-rich atmospheres.
• Considering use of active gas scavenging of space
beneath the drapes during oxygen delivery. When
scavenging under the drapes, exercise caution so
that the space beneath the drapes doesnʼt collapse.
• Avoiding the use of nitrous oxide during
bowel surgery.
During oropharyngeal surgery, ECRI
also recommends:
• Suction be used as near as possible to any potential
breathing gas leaks to scavenge the gases from the
oropharynx of an intubated patient.
Control combustible materials
Combustible materials – fuel that will burn – surround the
patient in the OR and include the operating table bedding,
headrests, clothing, straps, towels, drapes, sponges, dressings,
hair, intestinal gases, tracheal tubes, body tissue, broncho-
scopes, breathing systems, petroleum jelly, adhesives, hoses
Continued on Page 21
 Here’s a
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used in Teflon®, enabling them to be wiped clean
with a wet piece of gauze or sponge instead of an
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Medline is a registered trademark of Medline Industries, Inc.
and equipment covering – and this list is not complete. The insulation
Flammable and combustible liquids are also present in the failure provides
OR, including skin prep solutions, tinctures, degreasers, an alternate elec-
suture pack solutions and liquid wound dressings. trical current path
between the
Understanding what can burn and which liquids are flammable active electrode
or combustible is the first step in managing the fuel load for a and the patient
potential fire. Allow flammable liquid preps (e.g., preps that are return electrode,
alcohol-based or contain acetone) to fully dry before draping resulting in the
and avoid pooling the liquids when they are applied. Be aware burn. To minimize
that pooled liquids can be wicked up into sponges, drapes, capacitive cou-
etc. and may take longer to dry. ECRI recommends that facial pling, use an
hair (e.g., eyebrows, beards and mustaches) be coated with electrosurgical
a water-soluble surgical lubricating jelly to inhibit combustion.6 waveform with
the lowest volt-
Know and practice the fire plan age necessary
Service-specific fire plans have been required for many years. to achieve the
A fire plan is strongly recommend for surgical service. It should desired surgical
be reviewed annually and it is recommended that quarterly fire effect. Instruments that use active electrode monitoring tech-
5

drills be conducted. Surgical staff members should participate
in at least one fire drill (conducted in the OR) every year, and
it is especially important to:
• Talk about what each OR team member will do if presented
with a fire involving a patient.
• Walk through the plan and look for areas where response
can be improved.
• Know who will be responsible for moving the patient, where
the patient will be moved and who will be moving
critical equipment.
nology (AEM) are also effective in preventing capacitive
coupling.7 These devices are shielded and monitored so that
100 percent of their power is delivered where intended.
Refer to the Forms & Tools section starting on Page 76 to find
an Electrocautery Checklist and an Electrosurgical Cautery
Safety policy and procedure. For additional support materials
regarding fire prevention in perioperative services, refer to
AORNʼs guidance statement “Fire Prevention in the Oper-
ating Room.”

Not all burns are external References

Not all fires and burns are external to the patient. Internal fires
have been reported in the literature involving patients under-
going laparoscopic procedures in oxygen-rich atmospheres
(oxygen was mistakenly used for insufflation instead of
carbon dioxide). They have also been caused by the use of
lasers and non-metallic endotracheal tubes that were ignited
while in the patient. The burning endotracheal tube created a
1 Gamal M, Lamont C, Greene FL, eds. Review of Surgery Basic Science and
Clinical Topics for ABSITE. New York: Springer; 2006.
2 Kowalczyk L. Fires during surgeries a bigger risk than thought. Available at:
http://www.boston.com/news/local/articles/2007/11/07/fires_during_surgeries_a
_bigger_risk_than_thought/. Accessed July 15, 2008.
3 Joint Commission International Center for Patient Safety. Preventing Surgical
Fires: Who needs to be Educated? Available at: www.jcipatientsafety.org/15196.
Accessed July 15, 2008.
4 Cauterization. Available at: en.wikipedia/wiki/Cauterization. Accessed July 12,

fire similar to that which might have occurred had a blowtorch
scorched the lungs.
Stray electrosurgical burns can cause internal injuries that
2008.
5 DeRosier JM, Surgical Fires and Patient Surgical Burns. NCPS Tips – August/
September 2003. Available at: www.va.gov/NCPS/TIPS/Docs/TIPS_Aug_Sept_
03.doc. Accessed July 14, 2008.
6 Focus on surgical fire safety. ECRI Health Devices. 2003;32(1):4-40.

might be difficult to detect because they may not be visible to

7 Avoiding Electrosurgical Injury During Laparoscopy: An Emerging Patient Safety
Issue. [Videotape] Washington: Communicore; 1997.
the surgeon. Figures show that 67 percent of stray electro-
surgical burns go unnoticed during surgery and that 25 per-
cent of the patients who suffer internal injuries stemming from
these burns during laparoscopic procedures die.7 Insulation
failure on the electrosurgical device that results in burns and
capacitive coupling is cited as being the primary cause of
burns during laparoscopic procedures. With use, the tip of the
ESU can become extremely hot and, if inadvertently touched
to targeted tissue, can cause burns. Capacitive coupling can
occur if there is microscopic insulation failure in the device.

Aligning practice with policy to improve patient care 21

 Back to Basics Crossword Puzzle

Electrocautery Safety and

OR Fire Prevention
1 2

3 4

5 6

8 9

10

11 12

13 14

15

16

17 18

19 20

21 22 23

24

25 26

27 28

29

30

1. Register (free) or log in

www.medlineuniversity.com

2. Click Free Courses tab

3. Locate the puzzle and click Learn More,
then Begin Course
4. Certificates are available online after
puzzle completion

22 The OR Connection
Across
1 Electrical fires due to the improper use of electro-
cautery equipment are a potentially devastating
yet _____ adverse event.
4 Complications and patient injury due to improper
use of electrocautery devices include inadvertent
and advertent thermal injury, burn, _____, cardiac
arrhythmias and interference with pacemakers.
5 A common monopolar _____ is pen-shaped.
6 Use only active electrode tips that are manufactured
with _____ sleeves.
7 Electrocautery is most frequently used to stop the
bleeding of small vessels or for_____ through soft
tissue.
8 Cauterization began as a means to stop heavy
_____, especially during amputations.
9 To prevent electric shock, an alternating frequency
that is _____ than power from standard wall outlets
is used.
10 The placement of the return _____ is critical in
preventing extensive burns.
11 _____ fires have been reported involving patients
undergoing laparoscopic procedures in oxygen-rich
atmospheres.
13 Preventing a fire in the OR can be achieved by
controlling the elements that make up the
fire _____.
15 There are three conditions that must be in place for
a fire to occur: _____, oxygen and heat.
17 In bipolar cauterization, the active and receiving
electrodes are both placed at the site of _____.
21 Remove unneeded foot switches to avoid
_____ activation.
24 The typical bipolar probe resembles a pair
of _____.
27 Place the electrosurgical pencil in its _____ when
not in active use and place the electrosurgical unit
in the standby mode.
28 A fire _____ is strongly recommended for
surgical service.
29 When a higher _____ current is used in a pulsed
manner, tissue damage is more widespread and
blood coagulates.
30 _____ what can burn and which liquids are
flammable or combustible is the first step in
managing the fuel load for a potential fire.
To receive one hour of CE credit, enter your answers
online at www.medlineuniversity.com
Down
2 Do not use electrosurgery to enter the _____.
3 Do not use electrosurgery in close proximity to
_____ materials and oxygen-rich atmospheres.
12 Electrocauterization is the process of destroying
tissue with _____.
14 Different _____ effects can be achieved by
changing the voltage of the current as well as the
pattern of electric pulses.
16 Allow the tip of the pencil to be _____ only by the
individual wielding it and when it is under direct
observation of the surgeon.
18 Electrosurgery can be performed safely at “radio”
frequencies _____ 100 kHz.
19 With _____ cauterization, current is passed from
the active electrode, where cauterization occurs,
and the patientʼs body serves as a ground.
20 _____ of electrocautery pencils properly. For
example, break off the cauterizing wire and cap
the pencil.
22 It's important to understand that oxygen may
collect under drapes and in clothing and its
concentration become _____.
23 _____ reports that approximately 68 percent of
surgical fires involve electrosurgical equipment.
25 A grounding pad is placed on the patientʼs body,
usually on the _____, and serves as the returning
electrode, carrying the current back to the machine.
26 A _____ setting is available with most electrocautery
devices which allows for cutting and coagulation.
Aligning practice with policy to improve patient care 23
 The average
settlement in
malpractice cases
involving RFOs
is $50,000.2

24 The OR Connection

Left Behind
Retained foreign bodies harm
both patients and finances
By Megan Giovinco, RN, CNOR, RNFA
A 42-year-old woman presented with a five-month history
of abdominal pain, nausea and vomiting. Physical exami-
nation revealed a palpable epigastric mass. Five months
prior, the patient had undergone an abdominal hysterectomy
for uterine leiomyomata. The rest of her examination and
history were unremarkable. An abdominal computed tomog-
raphy (CT) scan was performed. Review of this and the Scout
image from the CT revealed a “density consistent with a
laparotomy sponge in the left lower quadrant of the
abdomen.” The patient returned to surgery for an exploratory
laparotomy and a sponge from her first surgery was found
and removed.1
How serious is the problem?
Gossypiboma, or retained foreign objects, are a dangerous
and costly issue.2 Current studies have found that retention of
sponges, sharps or instruments can occur as frequently as
one in every 100 cases or 1 in every 5000 cases. According
to the American College of Surgeons, any facility that
performs 8,000 to 18000 major cases annually will have one
incidence of a retained item yearly.3 These statistics are
based on claims data, but it is highly probable that even more
cases are settled outside the legal system every year. In
addition, it is likely that many more circumstances where
“near misses” – incorrect counts of sponges and instruments
that were identified and resolved intraoperatively via manual
searches and X-rays – have happened.4 The average settle-
ment in malpractice cases involving RFOs is $50,000. These
items that are inadvertently left behind when the surgical
incision is closed can cause pain, sepsis, bowel perforation,
Aligning practice with policy to improve patient care 25
Patient Safety
adhesions and death.2 If this was not enough to make surgical
facilities reexamine their count policies, the fact that they will
not receive their full Medicaid and Medicare reimbursements
if they fail to take steps to prevent eight avoidable hospital-
acquired conditions – including RFOs – will. In short, if a
patient must return to surgery to remove a foreign object left
behind during a previous procedure, the hospital will have to
foot the bill.5
Traditionally, the manual counting of sponges, sharps and
instruments has been a utilized standard of practice in the sur-
gical setting. Although helpful, there is no published data dis-
cussing the effectiveness of this practice.4 In fact, according
to a study done by the New England Journal of Medicine, in
almost 90 percent of cases involving a retained foreign ob-
ject, a count was performed per policy and all objects were
reportedly accounted for.6 Certain assistive devices such as
hanging bags to place sponges in, needle boxes on the sur-
gical field and wall-mounted boards for count documentation
have helped, but items continue to be left behind.4
How does this happen?
So why do items get left behind? The surgical team is made
up of dedicated and conscientious healthcare providers –
including anesthesiologists, surgeons, nurses and surgical
technicians – who are committed to a common goal of safe,
efficient and effective functionality. These professionals
constantly execute challenging tasks under considerable time
pressures, often in chaotic, constantly changing, stressful
situations.4 Although these practitioners have been trained

and have the experience to deal with such an environment,
human error can occur – especially when so many distractions
are present.7 Other risk factors that contribute to a greater
chance of something being missed include emergency surgery,
unplanned changes in the procedure, patients with a high
body mass index, multiple changes in the surgical team and
multiple operative sites.2
Well, what more can be done? As with many things, commu-
nication is key. Good communication between the surgical
team is necessary for the prevention of retained foreign
objects.8 Intraoperatively, distractions, interruptions, noise
and traffic should be as limited as possible. When staff
changes occur, complete and accurate transmission of
relevant information must be shared. This information
should also be documented according to facility policy. To-
ward the end of the procedure, the final count of surgical
sponges, sharps and instruments should be performed and
include a visual and audible confirmation by at least two
team members. This information should then be relayed to
the surgeon prior to closure of the surgical site.4
Although following these guidelines
will augment accuracy and reduce
errors, the fast pace and ever-
changing conditions of the OR
environment do not always allow
for them to take place as well as
they would in an ideal setting.
It is for this reason that surgical facilities must provide the
resources necessary to establish the safest OR environment
possible. 4 Counting policies should be re-evaluated,
revised and updated as needed in order to adapt them to the
specific clinical settings of each particular facility and to keep
26 The OR Connection
If a patient must return
to surgery to remove
a foreign object left
behind during a previous
procedure, the hospital
will have to foot the bill.
them up to date with AORN Standards and Recommended
Practices.9 These routine assessments of policy should also
include investigating any new tools or procedures available
that will increase patient safety and reduce retention
of counted items.6 Many institutions encourage obtaining a
routine X-ray of any case considered high risk for a RFO,
such as traumas or morbidly obese patients.3 However, it has
been noted in a recent study that three out of 29 X-rays
obtained for an incorrect count falsely reported that no
foreign objects were seen on the films.9
Technological advances
New technologies, such as radio frequency identification,
have recently been gaining acceptance in many of the
nationʼs ORs. Radio frequency ID-tagged sponges are elec-
tronically tagged with a small microchip about 4 x 12 mm in
size. This chip is small and sturdy enough that the sponges
that house it can be used the same way non-RFID sponges
are. Detection is still possible even if the gauze is balled or
folded up. One can even clamp directly over this chip without
impairing its functionality.10 By passing a hand-held, battery-
powered wand over the patient, one can detect whether or
not a sponge was left behind.9 These RFID chips are available
in sponges, gauze and towels in a variety of sizes. The wand
can also be used off the surgical field by the circulator to scan
for sponges that may have been inadvertently thrown into
the trash.10
This system is not meant to replace the traditional counting
system, but to augment it. Since the majority of retained
sponges happen when the counts are thought to be correct,
a clear scan and a reconciled surgical count give the scrub
nurse and circulator the assurance and peace of mind that
their findings are also correct.10 Clinical evaluations performed
by surgeons and perioperative personnel have rated the
RFID systems very highly for ease of use and the possibility
of decreasing the risk of incorrect counts.9
Continued on Page 28
Searching for that
one last sponge?

The RF Surgical® Detection System™ Are You Covered?

Perioperative nurses spend 15 to 30 stressful minutes As of October 1, 2008 Medicare will stop paying for
manually counting surgical sponges and instruments before, objects retained during surgery. Several major insurers
during and after each operation. Even with such protocols, are following suit.
studies suggest that given the 28.4 million inpatient opera- By helping prevent the occurrence and risk of retained
tions performed nationwide, more than 1,500 cases of a surgical objects, the RF Surgical Detection System sets a
retained foreign body occur annually in the United States.1 new standard of patient care and safety in the operating
According to Harvard University researchers, 88 percent of room and helps you avoid the cost of diagnosis, treat-
retained sponge cases falsely recorded a “correct” manual ment, re-operation, legal settlement and the time tracking
count of sponges at the end of the procedure, leading OR disposables.
staffs to unknowingly leave behind sponges in patients.
Developed and Manufactured
Prevent Retained Surgical Objects by RF Surgical Systems, Inc.
RF Detect® is the first easy-to-use scanning system to The RF Surgical Detection System
accurately detect and prevent retained sponges, gauze is exclusively distributed by
and towels in patients. Medline® Industries, Inc.
No larger than a grain of rice, RF Detect brings major
improvements in patient safety to the OR. For more information, contact
your sales representative or call
Reference
1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health
1-800-MEDLINE.
statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.
(PHS) 2001-1250 1-0287.).

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com
RF Detect® is a registered trademark of RF Surgical Systems, Inc.
RF Surgical® is a registered trademark of RF Surgical Systems, Inc.
 Performing surgical counts accurately and efficiently is one
of the first things taught to perioperative professionals.9
Everyone involved in the surgical procedure shares an ethical,
moral and legal responsibility to provide the patient with the
safest possible care. This includes assuring that no foreign
objects are retained where they can cause pain, harm,
further surgery or even death. To do this calls for the following
guidelines set up by the American College of Surgeons to be
followed:2
• Effective communication among perioperative staff
• Consistent application and adherence to individual facility
standards for counting procedures
• Performance of a methodical wound exploration prior to
closure of the surgical site
• Use of X-ray detectable items in the surgical site
• Maintenance of the most optimal OR environment possible
to allow for focused performance of tasks
• Use of X-ray and RF technology as indicated to ensure
there are no items remaining in the surgical field

There are many variables during the

count process that can potentially
lead to errors related to retained
foreign objects.
These include trauma situations, sudden changes in patient
status, obesity, noise and traffic in the room and staff changes
intraoperatively. However, it is still the number one priority of
all members of the surgical team to ensure the patientʼs
safety. OR personnel must utilize their knowledge and experience
and remain diligent and focused during the counting phases
of the surgical procedure so that no patient has to suffer from
References
1 Brown M, Schabel S. Retained laparotomy sponge. Applied Radiology.
2004;33(1).
2 Cedars- Sinai: OR Elimination of Retained Foreign Objects Taskforce. Nothing left
behind. Available at: www.csmc.edu/11749.html. Accessed July 18, 2008.
3 Jackson S, Brady S. Counting difficulties: retained instruments, sponges and
needles. AORN Journal. 2008;87(2):315-321.
4 Gibbs VC, McGrath MH, Russell, TR. The prevention of retained foreign bodies

a retained item.3
About the author
Megan Giovinco, RN, CNOR, RNFA, currently a clinical nurse
consultant, has been an RN for more than 10 years. Previously,
she worked as a nurse at a number of acute care facilities and
trauma centers.
after surgery. Bulletin of the American College of Surgeons. 2005;90(10).
5 Brandon G. Rule denying payments for “never events” will force a close look at
current practice. AORN Management Connections. October 2007:3(10).
6 The Joint Commission International Center for Patient Safety. Reducing the risk of
unintentionally retained foreign bodies. Available at:
http://www.jcipatientsafety.org/15199/. Accessed July 18, 2008.
7 RF Surgical Systems Inc. Retained surgical objects: costly to avoid and over-
come… until now. Available at: www.rfsurg.com/retainedobjects.htm. Accessed July
18, 2008.
8 American College of Surgeons. [ST-51] Statement on the Prevention of Retained
Foreign Bodies after Surgery. Available at: http://www.facs.org/fellows_info/state-
ments/st-51.html. Accessed July 18, 2008.
9 Murdock DB. Trauma: when thereʼs no time to count. AORN Journal. February
2008:87(2):322-28.
10 RF Surgical Systems Inc. Features. Available at: http://www.rfsurg.com/fea-
tures.htm. Accessed July 18, 2008.

28 The OR Connection
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 Patient Safety
World Health Organization Issues
Safety Checklist for Surgical Teams
By Laurie Barclay, MD and
Brande Nicole Martin
To improve surgical safety worldwide,
the World Health Organization (WHO) has
released a new safety checklist for surgical
teams to use in operating rooms, accord-
ing to a report regarding the Safe Surgery
Saves Lives initiative, published online
June 25 in The Lancet and also available
on the WHO Web site. These WHO guide-
lines and checklist are the first edition, and
they will be finalized for dissemination by late
2008, after completion of evaluation in 8 pilot
sites globally.
"Preventable surgical injuries and deaths are now a growing
concern," Margaret Chan, MD, director-general of WHO, says
in a news release. "Using the Checklist is the best way to
reduce surgical errors and improve patient safety."
High mortality and morbidity of major surgical procedures mandate
global public health and surveillance measures to improve
surgical safety, especially in low-income areas with limited
surgical access. Estimates suggest that about half of surgical
complications may be preventable.
The Safe Surgery Saves Lives initiative, a collaboration of more
than 200 national and international medical societies and
ministries of health led by the Harvard School of Public Health,
aims to reduce avoidable surgical mortality and morbidity. The
newly developed WHO Surgical Safety Checklist provides a set
of surgical safety standards applicable to all countries and
health settings.
At 8 pilot sites worldwide, preliminary findings from 1000
patients suggest that using the checklist has nearly doubled the
30 The OR Connection
likelihood that patients will receive a higher
standard of surgical care, with adherence
to these standards improving from 36% to
68%, and to nearly 100% in some hospitals.
Better adherence has been linked to
significant reductions in surgical morbidity
and mortality, although final results are not
yet available.
The checklist covers 3 phases of a surgical
procedure: before anesthesia is induced,
before skin incision, and before the patient
leaves the operating room. For each phase,
a checklist coordinator confirms that the team has com-
pleted the designated tasks before the next phase of the
operation occurs.
Before induction of anesthesia, key components of the
checklist, using the mnemonic "Sign In," are as follows:
• Check that the patient has confirmed their identity, the
surgical site, and the procedure to be done and that the
patient has given informed consent.
• The surgical site should be marked, if applicable.
• The anesthesia safety check should be completed.
• The pulse oximeter should be placed on the patient
and functioning.
• Check to see if the patient has (1) A known allergy. If so, these
should be documented. (2) An anatomically difficult airway to
intubate or aspiration risk. If so, additional equipment and
assistance should be available. (3) Risk of more than 500-mL
blood loss in adults or 7 mL/kg in children. If so, provision
should be made for adequate intravenous access and fluids.
Before skin incision, the checklist uses the mnemonic
"Time Out" for the following components:
• Confirm that all team members have introduced themselves
both by name and by their role on the surgical team.
• The surgeon, anesthesia professional, and nurse should
verbally confirm the patient's identity, surgical site, and
procedure to be performed.
• Anticipated critical events to be reviewed by the surgeon
are any critical or unexpected steps, estimated operative
duration, and anticipated blood loss.
• Anticipated critical events to be reviewed by the anesthesia
team are whether there are any patient-specific concerns.
• Anticipated critical events to be reviewed by the nursing team
are confirmation of sterility of the tools, supplies, and field
(including indicator results); documentation and discussion
of any equipment issues or concerns; whether antibiotic
prophylaxis has been given within the last 60 minutes, if
applicable; and whether essential imaging is displayed,
if applicable.
Lancet. Published online June 25, 2008. Reprinted with permission.
World Health Organization. Implementation Manual WHO Surgical Safety
Checklist (First Edition). Available at: http://www.who.int/patientsafety.
Aligning practice with policy to improve patient care 31
Before the patient leaves the operating room, the
checklist uses the mnemonic "Sign Out" for the
following components:
• The nurse verbally confirms with the team the name of the
procedure to be recorded and verifies instrument, sponge,
and needle counts, if applicable; labeling for the surgical
specimen, including patient name; and whether there are
any equipment problems to be addressed.
• The surgeon, anesthesia professional, and nurse review
the key concerns regarding recovery and management of
the specific patient.
The WHO notes that the checklist is not intended to be
comprehensive but encourages specific modifications and
additions appropriate for each local practice.
"Surgical care has been an essential component of health
systems worldwide for more than a century," says checklist
coauthor Atul Gawande, MD, MPH, a surgeon and professor
at Harvard Medical School in Boston, Massachusetts.
"Although there have been major improvements over the last
few decades, the quality and safety of surgical care has been
dismayingly variable in every part of the world. The Safe
Surgery Saves Lives initiative aims to change this by raising
the standards that patients anywhere can expect."
A copy of The WHO Surgical Safety Checklist can be found on Page 86
 Moments of Truth
How to enact a
culture change
at your facility
We hear a lot about culture change in health care these
days. Terms like “culture of safety,” a “just culture,” a “safety
culture” or the “culture of a high-reliability organization” pepper
the conversations of folks talking about patient safety and how
to improve it. Just what is culture and how do you go about
creating the culture you want?

By Stephen W. Harden

32 The OR Connection
 Special Feature

Defining culture
There are numerous definitions of culture. Everyone seems
to have their own take on it. After working with over 80 healthcare
organizations in the past eight years to help them create and
sustain a culture of safety based on the best practices of
high-reliability organizations, I have come to believe the
definition of culture is this: “The cumulative effect on the
organization of the actions of the people within the organization
at daily moments of truth.”

The heart of this definition is what people do at the daily

moments of truth. Intrinsically, you know what a moment of
truth is – the tens, if not hundreds, of little decision points
every healthcare professional encounters in the course of
their daily activities. A decision point is where a choice must
be made. You can do “A” or “B.” You can do something or
nothing. You can say something or say nothing. You can do
it the right way or use a work-around. You can do it mindfully
or thoughtlessly. Many of these decisions are decided almost
on the subconscious level, sometimes out of habit – without
even being aware of deciding.

The formula for culture change

So if we want to change culture, then we must influence what
happens at the thousands of daily moments of truth in an
organization. There is a simple formula for this. Remember
that “simple” does not always mean “easy.” This formula is
simple to understand and difficult to follow. The formula for
changing culture is this:

Thoughts + Actions + Habits + Character = Culture

Changing culture begins with changing how folks think at the

moment of truth. If you can change how they think, affect why
they do what they do, then you can change how they act at
the moment of truth. If we can change their thinking long
enough to affect how they act on a repetitive basis, then we
can help them develop habits. Habits are those actions we
take almost without thinking – itʼs just the way we “do busi-
ness” on a personal level. Changing habits changes our char-
acter. Character is what we do, again almost at the
subconscious level, especially when we think no one is
watching or no one will know.

Aligning practice with policy to improve patient care 33


Ultimately, culture is determined by the collective character
of all of the people in the organization. Their character is
determined by their habits. Their habits are determined by
how they repeatedly act at moments of truth. Their actions at
that moment are determined by how their thought processes
have been influenced. So if you want to change culture, you
must change character, and if you want to change character
you must change habits, and if you want to change habits
you must change repetitive actions, and if you want to
change actions you must change how people think.
In my experience, the most effective way to change how
people think is through leadership actions. These actions
include steps such as:
• Over-communicating what must be done, how it must be
done and why it must be done;
• Aligning all of the documents that describe how business
is done in the organization with the philosophy of how
it should be done;
• Public and repetitive acknowledgment and rewarding
of the desired actions at the moments of truth;
• Consistent coaching for those needing improvement and
willing to improve and
• Imposing negative consequences for those unwilling to
change how they think and act.
To change how people act at the moment of truth, training is
most effective. “Telling” is not training. Great training that
changes actions is experiential, inter-disciplinary, case study-
based, allows for practice and offers real-time feedback and
reinforcement on performance. Effective training gives both
the individual and the team an opportunity to practice the
34 The OR Connection
Leading a Change Initiative
"Your success in life isn't based on your ability to simply
change. It is based on your ability to change faster than
your competition, customers and business."
- Mark Sanborn
Questions to ask when considering change:
• What do we want to change?
• Why do we want to change?
• How are we going to change?
• Will change make things better?
Often, change does not bring about the desired out-
come, or is only temporary. Permanently changing the
culture of an organization requires taking the right
steps in the right order.
Is your team resistant to change? Listed below are
three key components required to leading an effective
change initiative:
1.Planning - Leading a change initiative requires a
compelling vision, a plan to achieve that vision,
and time to implement the plan. Anticipate potential
obstacles and plan for overcoming or avoiding them.
Achieve sustainability by anchoring your changes
into your organization's culture. Don't forget to
schedule in short-term win opportunities within
your long-term planning. This will encourage
forward movement.
2.Training - Provide training and support during
implementation. Plan for training of new-hires and
staff turnover as this will help to ensure sustainability.
Make certain the proper equipment is available to
support your change initiative. You can't successfully
run a new software program system-wide when most
of your team is still using dinosaurs for computers.
Avoid regression by celebrating the "battle won" too
soon, but celebrate your teams' successes along the
way as this will build confidence.
3.Human power - Are you adequately staffed to lead
this change initiative? Do you have champions in
place? Are your champions equipped with a common
vision? Avoid overburdening an already overburdened
team. Consider restructuring and adding new team
members to better ensure change and desired
outcome.
Reprinted with permission from LifeWings. To learn
more, visit www.saferpatients.com.
Continued on Page 36
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 actions needed in a learning environment so they will skillfully
be used at the moment of truth.

To ensure those actions are repeatedly used when needed

and therefore made into a habit, hardwired tools are most
effective. Tools such as checklists, protocols, communication
scripts, standardized communications and briefing guides
help people use the right action at the right moment. The tools
serve as a forcing function: if the tool is used correctly as part Continue your CE
of the consistent daily work flow, the individual has no choice
but to take the right action repeatedly and thus develops an
coursework at
effective habit. Medline
Little by little, moment by moment, person by person, habits University
are ingrained and character changes. When character
changes, the culture will change. Simple, but not easy. The Courses you can attend at any
beauty of the LifeWings methodology is that each of the time, from anywhere you have
components necessary to affect thinking, actions and habits
Internet access.
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Medline University offers more
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Perhaps your initiative will become guided by this quote from CE-credit courses.
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An affordable online resource.
Visit www.medlineuniversity.com
“Culture is the process by which a person
becomes all that they were created capable
of being.”
As you and I together continue to create and sustain cultures
where healthcare professionals are allowed to be capable of
all they were created to be, we will truly change the patient
safety landscape in this country.

About the author

Stephen W. Harden is President of LifeWings Partners LLC and
co-founder of Crew Training International, Inc. (CTI), the parent
company of LifeWings. Prior to his position at LifeWings, he was
the principal courseware designer of CTIʼs Crew Resource
Management (CRM) training for the U.S. Air Combat Command,
Air National Guard, Air Force Reserve Command, Italian Air Force,
Swiss Air Force, Belgian Air Force, domestic and commercial
airlines, construction crews and hospital surgical teams.

36 The OR Connection
Surgical Site
Infections
Are you playing your part
in prevention?

By Dayna Lowe, CST Instructor

Postoperative surgical site infections, also known as SSIs, are

quickly becoming the most common type of nosocomial
infection in patients undergoing surgery. They can lead to
increased morbidity, mortality, length of hospital stay and healthcare
costs.1 These infections number approximately 500,000 per year,
among an estimated 27 million surgical procedures.2 Postoperative
surgical site infections account for about one quarter of the estimated
2 million nosocomial infections in the United States annually.3

Everyone has a part to play in prevention

Postoperative surgical site infections are not to be taken lightly.
The occurrence and nature of SSIs vary from facility to facility, surgeon
to surgeon as well as from patient to patient. For the operating
room team, the warlike struggle against SSIs is complex. Each
team member caring for the surgical patient plays an important role
in the prevention of postoperative surgical site infections. Surgical
technologists, nurses, anesthesia care providers and surgeons
alike can greatly impact the outcome of each surgical procedure by
following the structured protocol proven to prevent postoperative sur-
gical site infections.
The surgical technologist
Surgical technologists have the primary responsibility for main-
taining the sterile field and remaining vigilant in verifying that all
members of the team adhere to an aseptic technique.4 Without this
constant vigilance by the surgical technologist, the occurrence of
inadvertent contaminations could go unnoticed and ultimately lead
to a postoperative surgical site infection. The dedication of the surgical
technologist to uphold this responsibility is known as a “surgical
conscience.” A surgical conscience is defined as “the ethical and
professional motivation that regulates oneʼs aseptic technique.”5
Along with a surgical technologistʼs close watch over the operative
field, the tech must be aware of which surgical procedures require
a clean and dirty instrument setup. For example, in a procedure
involving the gastrointestinal tract, the surgical technologist is
presented with the challenge of maintaining a clear definition
between instruments involved with the contaminated portion of the
procedure and the portion of the procedure that must remain sterile.
In order to do so, the surgical technologist must provide the members
at the surgical site with a sterile basin dedicated to the reception of
the contaminated instruments just before the surgeon opens the
bowel.6 Throughout the duration of this portion of the procedure, it
is imperative that the surgical technologist does not come in contact
Surgical technologists, nurses,
anesthesia care providers and surgeons
alike can greatly impact the outcome
of each surgical procedure by following
the structured protocol proven to prevent
postoperative surgical site infections.
with the instruments intended for use after the anastomos
is is completed.
This technique requires knowledge of anatomy as well as exceptional
organizational skills. A surgical technologist with a healthy surgical
conscience and a general understanding of the surgeries in which
they partake is a valuable team player in the fight against SSIs.
The circulating nurse
Prior to undergoing a surgical procedure, the patient is prepared for
surgery by the circulating nurse. This preoperative routine carried
out by the circulating nurse often involves hair removal and
decontamination of the surgical site. It is believed that preoperative
surgical site hair removal reduces infection rates; in contrast, some
methods of surgical site hair removal have been found to increase
the likelihood of SSIs.7 For this reason, healthcare facilities have
begun using electrical clippers verses the old-fashioned method of
dry shaving with a razor.
In addition to hair removal, the circulating nurse is most often
responsible for the decontamination of the patientʼs skin with an
antiseptic solution. The purpose of the skin preparation is to
reduce and ultimately remove pathogenic transient microorganisms
from the epidermal and dermal surfaces.5 The Association of peri-

Aligning practice with policy to improve patient care 37

 THESE INFECTIONS
Operative Registered Nurses states
that when selecting antiseptic
agents, one should take into
consideration the types of tissue
number approximately
involved. AORN emphasizes
that one should choose an agent 500,000 per year, among
with a broad range of germicidal
action and also apply it in accor-
an estimated 27 million
dance with the manufacturerʼs surgical procedures.2
written instructions.
The circulating nurse also plays a crucial role in maintaining the
patientʼs body temperature, which can greatly influence the risk
of SSIs. Although it seems more of a courtesy than structured
protocol, the provision of warm blankets can ensure the patientʼs
core temperature is at the homeostatic state at the time
of induction.
The anesthesia care provider
Attention to the patientʼs body temperature is a standard of care
in anesthesia management. Operating rooms are kept at a
cool temperature because it has long been believed that
doing so minimizes the risk of infection. Recent studies suggest
that this is not the case at all. Lowering the core body tempera-
ture causes dermal vasoconstriction and reduced blood flow to
surgical sites, thus taking away life-sustaining oxygen.8 Both
regional and general anesthesia can cause the bodyʼs core
temperature to drop. In an attempt to prevent intraoperative
hypothermia, the anesthesia care provider often employs the
use of a forced-air warming blanket.
Another action the anesthesia care provider takes that aids in
the patientʼs ability to avoid an SSI is the administration of the
prophylactic antibiotic(s) in a timely manner. In fact, two national
organizations, the Centers for Disease Control and Prevention
(CDC) and the American Society for Health System Pharmacists
(ASHP), have recently collaborated to provide medical caregivers
with guidelines regarding the administration of prophylactic
antibiotics for a variety of procedures.9,10 Administration of
antibiotics, usually intravenously, should be timed so that a bac-
tericidal concentration is present in blood and tissues by the time
the surgical incision is made and maintained until closure of the
surgical site. Because of the overwhelming positive impact of the
studies done on the administration of prophylactic antibiotics, it is
now a standard of care and recommended practice in most
healthcare facilities.
In addition to the responsibilities discussed above, the anes-
thesia care provider is accountable for monitoring the patientʼs
blood oxygen saturation. Decreased oxygen levels devital-
ize tissue and increase the risk for bacterial colonization.11
Providing the patient with an oxygen supplementation involves
the delivery of 80 percent oxygen and 20 percent nitrogen
through the use of an endotracheal tube, a sealed mask, a
manifold system or a conventional non-rebreather mask for the
first two hours of recovery. Oxygen is increased to 100 percent
38 The OR Connection
immediately before extubation,
with the concentration returned to
80 percent by the anesthesiologist.12
The surgeon
The surgeon is the individual most
responsible for prescribing the
preoperative antibiotics. Preoper-
ative administration of antibiotics
is a course in prevention. The
rationale suggests that if there is
an infusion of antibiotics in the tissue prior to incision, there is
less of an opportunity for opportunistic bacteria to find a home
in the patientʼs surgical incision. An intricate combination of
timing, selection, duration and discontinued use is vital to the
success of an antibiotic.
In a successful surgery, each individual team member plays an
important role. Although certain tasks and preoperative routines
are delegated to the staff, a system of accountability is useful to
maintain an ideal approach to preventing SSIs. A medical
caregiverʼs continued education in the advances in aseptic tech-
niques, and overall prevention of surgical site infections, can
help ensure a smooth, infection-free recovery for the patient.
About the author
Dayna Lowe has been a surgical tech-
nologist for six years. She currently works
at a smaller hospital in Florida and as an
Instructor of Surgical Technology at Central
Florida Institute.
References
1 Perl T. Identification of Risk Factors Associated with Surgical Site Infection following Spinal Sur-
gery. Study currently underway at Johns Hopkins University.
2 Centers for Disease Control and Prevention. National Center for Health Statistics. Detailed
Diagnoses and Procedures, National Hospital Discharge Survey, 1994. Hyattsville, Md.: Department
of Health and Human Services; 1997.
3 Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection
rate: a new need for vital statistics. Am J Epidemiol. 1985;121:159-67.
4 Commission on Accreditation of Allied Health Education Programs. Surgical Technologist. Avail-
able at: http://www.caahep.org/Content.aspx?ID=53. Accessed July 1, 2008.
5 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. St. Louis, Mo.: Elsevier Saunders;
2005.
6 Alexander FM. Maintaining a sterile field during gastro-intestinal surgery. The American Journal
of Nursing. 1952;52(6):705-07.
7 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004122.
8 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-
wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
N Engl J Med. 1996;334:1209-15.
9 American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial
prophylaxis in surgery. Am J Health Syst Pharm.1999;56:1839-88.
10 Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory
Committee. Guideline for prevention of surgical site infection. Am J Infect Control. 1999;27:97-132.
11 Hopf HW, Hunt TK, West JM et al. Wound tissue oxygen tension predicts the risk of wound in-
fection in surgical patients. Arch Surg. 1997;132:997-1004.
12 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the
incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med. 2000;342:161-67.
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 Great Ideas from Your Peers
Surgical Skin Prep Solutions
At St. Vincentʼs Medical Center in Indianapolis, Indiana,
Paul Durgan, staff educator for surgery, came up with
an innovative way to assist surgical personnel in
providing the most effective prep solution in an
efficient and cost-effective manner. Paulʼs goals were
to offer a high-efficacy surgical prep solution while simul-
taneously reducing the waste associated with the facilityʼs
current prep kit. He had observed staff members
discarding most of the contents in their current prep
tray and adding their preferred solution.
The CDC strongly recommends using 2 percent chlorhex-
idine (CHG) solution for skin antisepsis. Two percent
chlorhexidine solution has been shown to be six times
more effective than alcohol and povidone-iodine in
cleaning the skin and in inhibiting microbial growth for
days afterward.1 In two studies measuring persistent
efficacy, chlorhexidine demonstrated significant residual
antimicrobial effects for five days and was more effective
than isopropyl alcohol, alcohol or povidone-iodine alone.1
Paul had the opportunity to attend a seminar in which Dr.
Allan Morrison Jr., an epidemiologist and chairperson of
Infection Control at Inova Fairfax Hospital and clinical
assistant professor at Georgetown University Hospital,
discussed the benefits of chlorhexidine as a surgical prep
40 The OR Connection
By The OR Connection staff
solution, particularly as it relates to reducing facility-
acquired infections following surgical procedures.
This led to the idea of creating a custom surgical prep tray
that only contained supplies that could be used in almost
every procedure. Of course, Paul wanted to be sure that
chlorhexidine was the preferred prep solution, so they
choose a four-ounce bottle containing 4 percent CHG.
Additional components in the tray include 100 ml saline
(for diluting or rinsing), three sponge sticks, six winged
sponges, two cotton swab applicators, two blue cloth towels
and two white cloth towels. They chose cloth towels for
better absorbency and also because they have much less
memory than a paper towel, which can spring back after
placement and lead to cross contamination.
Creating a custom surgical prep
tray enabled St. Vincent’s to realize
a 29 percent cost savings over their
previous trays. They lowered their
per-tray cost by $2.78.
Because CHG cannot be used to prep eye, ear or genital
procedures, the need for additional prep solutions is appar-
ent. Paul is actively searching for a CHG prep that can be
used on genital areas and will let us know when he finds
his next solution.

St. Vincentʼs orthopedic department has also recently
initiated a study with their total joint patients, asking them
to shower with CHG the night before their surgery. The
CDC also recommends that surgical facilities require
patients to shower or bathe with an antiseptic agent at
least the night before surgery.2 Additional information will
be shared as the results of this study become available.
Components of the Custom Surgical Prep Tray
• Four-ounce bottle of 4 percent CHG
• 100 ml saline (for diluting or rinsing)
• Three sponge sticks
• Six winged sponges
• Two cotton swab applicators
• Two blue cloth towels
• Two white cloth towels.
Aligning practice with policy to improve patient care 41
OR Issues
Improved efficiency, decreased waste, better patient care
and cost savings are all the results of one innovative
change. Whereas there is often a perception that
customization leads to increased cost, when you find that
standardized solutions result in throwing away supplies
that are not wanted or used, one can easily see where
customization can provide a cost effective solution.
Paul Durgan has been the staff educator for surgery at St.
Vincentʼs Medical Center in Indianapolis, Indiana, since 2005.
Paul says that this position has helped him “attain a broader
perspective of current needs for patient care as well as physician
and associate satisfaction.” He credits the development of the
CHG prep kit as an area in which he was able to promote a cost-
effective solution to one of his facilityʼs needs.
References
1 Hibbard J et al. A clinical study comparing the skin antisepsis and safety of
ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. Journal of
Infusion Nursing. 2002;25(4):244-49.
2 Nichols RL. Preventing surgical site infections: A surgeon's perspective.
Emerging Infectious Diseases. 2001;7(2).
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only completely conforms to the patient’s body contours and
Pressure Free
gently cradles delicate bony prominences but keeps its shape
OR table pad
throughout even the longest procedure. All of this is encased in
our state-of-the-art Proknit ticking to eliminate the “hamocking
effect” seen in other vinyl pads.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Flipping the Switch on Pressure
How to help reduce your patients’
pressure ulcer risk
By Jayne Barkman, RN, CNOR
After a leisurely lunch in the outdoor café, Sandy and Joe
checked their afternoon assignment. They were to relieve
the staff in OR 31. Sandy and Joe entered the OR through the
sterile core as the surgeon was initiating the time-out. Joe
opened his gown and gloves while Sandy received report from
the circulating nurse. The patient was a young anorexic woman
with no known allergies who was undergoing a right thora-
coscopy and chemical pleurodesis for recurrent pneumothorax.
She was positioned in a lateral position right side up on a
bean-bag positioner. A towel roll was placed under her axilla.
Her arms were padded with foam and pillows and secured on
arm boards with two pillows placed between her legs. She was
secured to the OR bed by a safety strap across her thighs as
well as tape across her hips.
After he was gowned and gloved, Joe handed Sandy the light
and camera cords. The surgeon asked for the room lights to be
Aligning practice with policy to improve patient care 43
Patient Safety
dimmed and then the case was underway. This will be a quick
case, Sandy thought to herself as she opened the vial of sterile
talc to the field. She finished her computerized charting and,
within what seemed like minutes, Joe was ready to do the first
closing count. After they completed their counts, Sandy opened
the chest drainage tubing to the sterile field and filled the chest
drain with water. The second counts were completed soon after
and Sandy called for moving and lifting help as Joe placed the
dressings over the small incision sites.
Joe removed the drapes from the patient as the surgical assis-
tants brought the stretcher into the room and stood at the side
of the operating room table in preparation for repositioning of
the patient for extubation.
Joe asked Sandy to step around to his side of the OR bed. He
pointed to an area where a portion of the draw sheet covering
 the bean-bag positioner had Sandy agreed and said she would
shifted during the procedure and talk to Sue, the director, to get the
the decompressed bean bag in-service scheduled as soon as
IT IS IMPERATIVE
was pressed directly against the when positioning the patient that possible.
patientʼs skin. The standard of
care at their hospital for lateral all potential pressure points are How to take the pressure
positioning of patients included off your patients
placing foam padding between In the perioperative environment,
adequately padded as well.
the patient and the bean bag as nurses are presented with myriad
well as placing a gel roll under challenges when caring for their
the axilla and foam padding under the patientʼs heels. After the patients. Careful attention is given to keeping the patientʼs
bean bag was compressed to reposition the patient, Sandy and body in proper alignment when positioning in order to prevent
Joe assessed the patientʼs skin. A three-inch-long reddened postsurgical neuropathies. It is imperative when positioning
area was noted along the patientʼs mid-thoracic spine where the patient that all potential pressure points are adequately
the bean bag had come into direct contact with the skin. padded as well. When using linens, such as blankets and towels,
for rolls or positioning devices or placing a patient on a thin OR
When the anesthesiologist was ready, the patient was lifted and mattress, you could inadvertently be placing your patient at risk for
placed in a supine position. Sandy assisted the anesthesiologist pressure ulcer formation. Linens, which are readily available in
with extubating the patient and asked Joe to assess the most operating rooms, are often used for positioning patients
patientʼs ankles and feet for any pressure areas. Joe noted a but do not reduce pressure and may result in unrelieved areas
quarter-sized reddened area on the patientʼs left lateral of pressure or friction injuries.1
mallelous. When the patient was rolled onto her right side to
place the transfer device under her, Sandy noticed a plum-sized Studies have indicated that when the
reddened area below her left axilla, yet another pressure area.
The patient was lifted onto the stretcher and transported to the
patient is unable to move during
CVICU. When relaying report to the CVICU nurse, Sandy surgery, it is important that the
pointed out the reddened areas on the patientʼs back, left axilla weight of the patient be uniformly
and ankle as pressure points that needed close monitoring
postoperatively.
distributed on a firm, stable surface
that conforms to the patient, such as
Back in the OR and helping with room turnover, Sandy and Joe a gel or thick foam mattress pad.2
shook their heads. The hospital policy clearly indicated that
foam or gel pads were to be used to pad areas of potential pres- The amount of pressure and the length of time pressure is
sure on all surgical patients. applied to the skin are both critical factors in pressure ulcer
formation. Studies have indicated that high pressure for a short
As representatives on the patient care council, Joe and Sandy time and low pressure for a longer duration have the same
were aware that an order had been placed for additional gel effect on potential tissue damage and the likelihood of pressure
rolls and pads – as these items had virtually disappeared from ulcer formation.2 When pressure is applied to the skin, blood
the OR – and that new pressure-free operating table mat- flow is decreased, leading to potential skin breakdown and
tresses had been ordered for each of the operating rooms to tissue necrosis.3
replace the old table pads, some of which were cracked and
repaired with tape. Pressure ulcer prevention had also been While extrinsic factors such as shear, force friction and pressure
added to the hospitalʼs required annual competency education predispose a surgical patient to the development of pressure
for 2009. Joe suggested to Sandy that the next OR in-service ulcers, intrinsic factors such as the patientʼs nutritional status,
be dedicated to an interactive positioning in-service where staff age, mobility and mental and continence status also place the
volunteers were placed in various positions and could verbally surgical patient at risk of pressure ulcer formation. Recent
relay to their coworkers the areas that felt uncomfortable so the research, however, has indicated that pressure may be the
staff had an understanding of direct areas of pressure patients single most important factor in the formation of pressure ulcers
experience when positioned during their surgical procedures. intraoperatively.3

44 The OR Connection
 Intraoperatively Acquired Pressure Ulcers4,5,6
• Initially appear as a burn like lesion. About the author
Jayne Barkman, RN, BSN, CNOR, has 29 years of perioperative
• Occur most frequently in patients undergoing general,
experience in various roles, including surgical technologist, staff nurse
thoracic, orthopedic, cardiac and vascular procedures. and clinical educator. She currently works as a clinical nurse consultant.
• Have been documented to occur in 12 percent to 66
percent of surgical patients.
• Account for 42 percent of nosocomial-acquired References
pressure ulcers. 1 AORN. Recommended practices for positioning the patient in the
• Add an additional cost of up to $60,000 per patient or perioperative practice setting. In: Standards, Recommended Practices,
and Guidelines. Denver, Colo.: AORN, Inc; 2006:587-590.
750 million to 1.5 billion dollars annually.
2 Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention:
An analysis of bedding materials. Research in Nursing & Health.
1994;17(5):333-39.
3 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB,
Typically, perioperative nurses have no contact with the patient
Gebhart GH, Ma EK. Pressure ulcer prevention. J Long Term Eff Med
postoperatively and therefore the ramifications of intraopera-
Implants. 2004;14(4):285-304.
tively caused pressure ulcers are unknown to the perioperative
4 Pressure Ulcers Risk Analysis (Healthcare Risk Control November
staff. The Association of periOperative Registered Nurses
2006). Available at: www.ecri.org/documents/patient_ safety_center/
(AORN) recommends doing a thorough preoperative interview
pressureulcers.pdf. Accessed July 23, 2008.
and assessment to determine the appropriate positioning
5 Ankrom MA, Bennett RG, Springle S et al. Pressure-related deep tissue
devices required for each individual patient. Their guidelines
injury under intact skin and the current pressure ulcer staging systems.
state that the perioperative nurse should be involved in
Advances in Skin & Wound Care. 2005;18(1).
positioning the patient as well as monitoring for proper body
6 Wilhelmi BJ. Pressure Ulcers, Surgical Treatment and Principles. Avail-
alignment and the tissue integrity of the patient after position-
able at: http://www.emedicine.com/plastic/topic462.htm. Accessed July
ing and during the surgical procedure. A skin assessment
23, 2008.
should be repeated when the procedure is finished with docu-
mentation of the assessment. The recommended practices also
state that positioning policy and procedures should be acces-
sible to the staff and be reviewed and revised annually.1

Aligning practice with policy to improve patient care 45

 Patient Safety

46 The OR Connection
 By Claudia Sanders, RN, CFA

Pressure ulcers can develop within two to six hours of the

onset of pressure. Incidence is over 60 percent for high-risk
patients with femoral and/or hip fractures. Elderly patients with
hip fractures have the greatest incidence of new-onset post-
operative pressure ulcers, which typically occur within the first
two postoperative days. About 70 percent of all pressure
ulcers occur in people older than 70 years. Have you had a
patient in your OR lately who was 70 years old with a hip or
knee fracture?

5
GIMME There are many contributing factors for pressure
ulcers, including:
• Circulation
• Mechanical stress
• Temperature
• Too wet/ too dry (moisture)
• Infection
• Chemical stress
• Medications
• Disease
• Nutrition
• Age
• Body build

Five pressure ulcer
factors to keep in mind
A number of these factors are out of our control, but others can
be affected positively with the appropriate tools and practices.
Following is a list of five of these factors and some considerations
you will want to examine the next time you are caring for
patients at risk for pressure ulcers.
1. Age
It should come as no surprise that the older we are, the more
fragile our skin becomes. Skin becomes thinner, drier and has
a tendency to break down easily. The elderly are also at a
higher risk for poor circulation. Clearly, these patients need to
be handled with gentle and caring hands.

Keep in mind how long you may have this patient lying on a
stretcher in a holding area. Ask the patient to move themselves
if possible or encourage and help move the patient if they are
lying in one position for long periods of time. And pad those
areas where pressure ulcers most commonly occur when
patients are lying down: back of the heels, knees, buttocks,
tailbone and hipbone. Same goes for when you have
brought the patient into the operating room and placed
him on the operating room bed. Proper positioning of the
patient and padding of bony prominences is vital in preventing
pressure ulcers while patients are in surgery. Your facility may
want to invest in gel table pads for stretchers and operating
room beds as well as gel positioners.

Aligning practice with policy to improve patient care 47

 2. Body build
There are two body types that are especially susceptible to
pressure ulcers: obese patients and extremely thin patients.
Obese patients are a higher risk due to poor circulation to fatty
tissues. Poor circulation means less oxygen, reduced nutrition
and more risk for pressure ulcers. When appropriate, be sure
to use compression stockings to help with circulation and, of
course, assist in preventing deep vein thrombosis (DVT). Do
whatever you can to improve circulation. This may mean using
minimal sutures in the subcutaneous layer. Handle obese
patientsʼ tissues with care and consider preoperative and post-
operative oxygen use.
Extremely thin patients are also at risk because there is less
fatty tissue to “cushion” them. This means their bony promi-
nences are even more susceptible for skin breakdown
compared to the average-sized patient. We cannot overstress
the importance of padding these areas and padding them with
care so as to reduce friction that can lead to skin breakdown.
3. Chemical stress on wounds
As with all surgical procedures, we must first prep the area
where the incision will be made. This requires chemical products
of one kind or another, depending on the surgeonʼs preference.
Such chemicals may include povidone-iodine, hydrogen
peroxide, alcohol, acetic acid or iodophors. All these chemicals
have an important part in reducing infection, but at the same
time they can contribute to skin breakdown. This is a great time
to “think outside of the box” and consider what compromises
the patient has before choosing your preps. In conditions of
extremely compromised skin, consider rinsing with a prep
solution and monitor how hard you rub or clean the operative site.
5. Infection
When caring for surgical patients with infection, there are extra
considerations to keep in mind. You know your patientʼs skin is
already compromised by infection and that their immune
system is also compromised. This compromises healing, which
can set patients up for pressure ulcers.
To help prevent pressure ulcers from forming, position the
patient properly (and pad bony prominences), help maintain
good body temperature (keep the OR at a reasonable
temperature) and help maintain the ideal skin moisture
environment (if necessary, use pads to help wick moisture from
the patient). Of course, you also want to prevent cross
contamination of infection from an open wound to other parts
of the body. Consider using skin barrier-type products on the
surrounding areas before prepping an infected wound.
Keep in mind that this is an area we have all dealt with at one
time or another – but with the occurrence of these pressure
ulcers on the rise and changes to reimbursement policies, it is
time to revisit our practices.
About the author
Claudia Sanders, RN, CFA, is currently a
clinical nurse specialist. She has practiced in
the medical field for more than 30 years as
a surgery technologist and periopera-
tive nurse.

4. Too wet/ too dry (moisture)

Most of us know the story of Goldilocksʼ search for porridge
and a bed that were “just right.” Well, the skinʼs moisture needs
to be “just right” as well – not too wet and not too dry. When
caring for surgical patients, we need to help maintain this
environment by being mindful of the solutions we use and how
we use them. Donʼt let prep solutions “pool” on or around the
patient. Prep solution can often run down into the creases of
the femoral, buttocks and lower back areas, not to mention the
axillary and neck areas. Do what you can to prevent this and
clean these areas before sending the patient to the recovery
room so these chemicals will not continue to sit on the skin.
Be gentle with this process, especially with the compro-
mised patient.

48 The OR Connection
Join the program
to reduce pressure ulcers.
Medline’s Pressure Ulcer Prevention Program The Pressure Ulcer Prevention Program from Medline will help
you in your efforts to reduce pressure ulcers in your facility.
Systematic efforts at education, heightened awareness and
specific interventions by interdisciplinary healthcare teams
The program includes:
have demonstrated that a high incidence of pressure ulcers
• Education for professional staff and nurse technicians
can be reduced.1
• Teaching materials for you to help train your staff
• Practical tools to help reduce the incidence of pressure ulcers
The main challenges to having an effective pressure ulcer
• Innovative products supported by evidence-based information
prevention program are lack of resources, lack of staff education,
that results in better patient care
behavioral challenges and lack of patient and family education.2

To join the fight against pressure ulcers and for more

Medline’s comprehensive Pressure Ulcer Prevention Program
information on the Pressure Ulcer Prevention Program,
offers solutions to these challenges to promote the reduction
please contact your Medline sales representative or
of pressure ulcers with clinical and educational resources,
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assessment tools and a complete compatible product line,
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References

www.medline.com
1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 The History of the

SURGICAL
TECHNOLOGIST
50 The OR Connection

By Jennifer Bray, SST and Greg Warino, SST
The workplace is full of a wide variety of job titles and
initials to place behind your name. They often sound
significant, but did you ever wonder where they came
from? What caused a need for the professions (and pro-
fessionals) of today? At some time, every vocation was
new, including that of the surgical technologist. So what
spurred the need for them?
The advances in medical technology, from antibiotics to
blood transfusions, have often come during times of war.
This same setting fostered the need for surgical technol-
ogists. Initially, the role of the nurse basically entailed
assisting the surgeon during procedures. However, as
various wars depleted nursing resources, other ways of
providing patient care during surgery had to be explored.1
In 1939, Dr. Thomas Parran Jr. (then the U.S. Surgeon
General) proposed the Protective Mobilization Plan, which
pushed for the training of enlisted medical and surgical
What Does a Surgical Technologist Do?
What roles do surgical technologists play on any given day?*
• Prepare patients for surgery - draping, positioning
In the OR, they
and establishing the sterile field
• Set up surgical instruments and equipment
• Gloving
• Pass instruments and sterile supplies to the surgeon
• Ensure the integrity of the sterile field throughout the procedure
• Cut sutures
• Perform surgical counts of sponges, needles, supplies
and instruments
Aligning practice with policy to improve patient care 51
OR Issues
technicians. According to this plan, schools were to be
established at the Army Medical Center and four other
general hospitals for the formal education of surgical tech-
nologists. Prior to this, technicians were simply trained on
the job.2
It was not until 1940 that Dr. Parranʼs plans began to be
executed. In 1941, the first school of surgical technology
was in session. By July of 1942, 410 students were
enrolled. With the entrance of the United States into World
War II, there was an even greater need for surgical
personnel. More schools were quickly established and the
number of “scrubs” more than doubled in order to meet
the demand of the military hospitals both at home and
abroad.2
The nursing shortage worsened as the war continued and
more and more wounded soldiers were in need of care.
Nurses were in great demand to staff not only local facil-
• Prepare, care for and dispose of specimens
• Apply dressings
• Operate lights and suction machines
• Assist with diagnostic equipment
• Manage central supply departments
Outside of the OR, they
• Represent surgical instrument manufacturers
and sterile supply services
* Association of Surgical Technologists. The Surgical Technologist. Available at:
http://www.ast.org/ads_exhibits/index.aspx. Accessed June 17, 2008.
 ities but the hospitals and medical units of distant erative Registered Nurses (AORN) was formed. This
military bases and battlefields as well. Because of this, group would play a major role in the development of the
more corpsmen were trained to assist surgeons during surgical technologist into a formal part of the surgical
procedures. They were also trained to perform tasks such team.4 In 1968, AORN formed the Association of Operating
as anesthesia administration, instrument preparation, aid Room Technicians (AORT) and formal training for surgical
in clamping and retraction intraoperatively and closure of technologists began at proprietary schools. AORN also
surgical incisions. The title Operating Room Technician, helped establish certification credentialing for surgical
or ORT, was established.1 technologists. The AORT initiated the first certifying exam
and gave those who passed it the title of Certified Operating
Early education Room Technician (CORT).1
In the beginning, medical and surgical technologist
students were taught together for the first month and then In 1972, the American Medical Association formally
separated for their clinical instruction. Surgical technologists approved an educational program for the OR technician.
were assigned to hospital In 1978, the Association of
wards or a surgical service. Operating Room Technicians
According to the Surgeon changed its name to what it is
Generalʼs plan, the surgical now known as – the Associa-
course was to only take two tion of Surgical Technologists.5
months. However, it was
quickly determined that more From the humble beginnings
time was needed to train of nothing but on-the-job train-
these students effectively. ing to a nationally recognized
In 1943, the course was association and credentialing
extended to three months certification, the profession of
with only a month of on-the- Authors Greg Warino, SST and Jennifer Bray, SST are the surgical technologist has
job training.2 currently enrolled in the surgical technologist program certainly come a long way. In
at Central Florida Institute in Clearwater, Fla.
the years since Dr. Parranʼs
In 1942, advanced training was offered to select individuals original plans were developed, hundreds of schools of
who had completed the surgical courses. These technol- surgical technology have been established throughout the
ogists were prepared to replace nurses in the forward United States and thousands of students have graduated.
combat areas or to become instructors of future students. Many of these students have also gone on to earn their
Most of their training was provided by nurses in the hospital certification as a surgical technologist (CST), their First
setting. Unfortunately, despite the specialized training and Assistant qualification (CFA) or become instructors.5 The
service these advanced practice technicians provided, professionals who carry these initials behind their names
they were never recognized by the military. This training have this amazing historic timeline to thank for the
ceased in 1945.3 rewarding career they have chosen.

Moving into the modern day References

1 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, Pa: W.B.
Since the infantry was depleting the Medical Corps of its Saunders; 2005.

male technologists, the department began accepting 2 Office of Medical History, Office of the Surgeon General. Medical Department, United
States Army Medical Training in World War II. Available at:
women into its programs in 1943. The Surgeon General http://history.amedd.army.mil/booksdocs/wwii/medtrain/frameindex.html. Accessed June 17,

requested the recruitment of even more women in 1944. 2008.

3 Association of Surgical Technologists. Surgical Technology for the Surgical Technologist:
So many women answered the call to duty that schools of A Positive Care Approach. 3rd edition. Clifton Park, NY: Delmar Learning; 2008.

surgical technology had to be expanded yet again.3 4 Association of periOperative Registered Nurses. AORN History. Available at:
http://www.aorn.org/AboutAORN/AORNHistory/. Accessed June 17, 2008.
5 Association of Surgical Technologists. About AST. Available at: http://www.ast.org/abou-

The nursing shortages caused by World War II and the tus/about_ast.aspx. Accessed June 17, 2008.

wars that followed it forced operating room supervisors to

question the need for trained non-nursing personnel to
assist during surgery. In 1949, the Association of periOp-

52 The OR Connection
Medline’s Hand Hygiene
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1
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hygiene is the number one • A cost calculator to help you determine the cost of
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There’s no such thing as • Patient and family education materials
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References
1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and
fiscal year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20,
2007.

2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 Special Feature

A Place of Healing?
Violence is increasingly
common in health care
By Laura Kuhn
The OR Connection staff writer
Itʼs ironic when you stop and think about it – hospitals are
places where patients go to get better, yet for some
healthcare employees theyʼre also places fraught with
intimidation, harassment and even violence.

The extent of the problem

According to the Council on Surgical and Perioperative Safety
(CSPS), violence in the healthcare workplace is a growing
concern and nurses are at a particularly high risk.1 Between
1996 and 2000, there were 69 homicides reported in the
health services field.2 Twenty-five of every 10,000 full-time
nurses were injured in workplace assaults in 2000. In contrast,
injuries due to workplace assaults occur in only two of every
10,000 employees in most private-sector industries.2

As disturbing as these numbers are, it is estimated that the

actual number of incidents is much higher.2 Violent incidents
often go unreported, possibly due to the perception that
assaults are “part of the job” in the healthcare industry.2 Other
reasons for underreporting include the lack of a solid institu-
tional reporting policy, the belief that reporting will not benefit
the employee and the fear that the report could be viewed by
employers as employee negligence or poor job performance.2

Many patients who are treated in hospitals

and other care facilities are at an increased
risk of exhibiting violent behavior.

54 The OR Connection
Obviously, healthcare workers can’t control
which patients come through the doors of their
facilities. They can, however, have a strategy
in place for preventing violence and effectively
halting it when it does happen.
Defining violence in the workplace
The CSPS defines workplace violence and its elements in its
Statement on Violence in the Workplace1:
Workplace violence includes, but is not limited to, intimidation,
threats, physical attack, property damage and sexual harassment.
Intimidation includes, but is not limited to, stalking or
engaging in actions intended to frighten and coerce.
Threat is the expression of intent to cause physical or
mental harm.
Physical attack is unwanted or hostile physical contact such
as hitting, fighting, pushing, shoving or throwing objects.
Property damage is intentional damage to property.
Sexual harassment is unwelcome advances, requests for
sexual favors, and other verbal or physical conduct of a sexual
nature, when submission to or rejection of this conduct
explicitly or implicitly affects a person's employment or
education, unreasonably interferes with a person's work or
educational performance or creates an intimidating, hostile
or offensive working or learning environment.
Triggers for violence in the healthcare workplace
Many patients who are treated in hospitals and other care
facilities are at an increased risk of exhibiting violent behavior.
Medical conditions associated with violent tendencies include
hypoglycemia, electrolyte imbalance, anemia, hypoxia, alcohol
intoxication, pain, dementia and the use of codeine, PCP,
LSD and other drugs.3 However, while these factors might
make a person more likely to behave in a violent manner, the
individualʼs tendency toward violence must still be triggered in
some way.4 These triggers are referred to as “situational factors.”4
There are a number of situational factors present in hospitals
that can contribute to violent behavior. These include poor
environmental design, inadequate security, access to
firearms, poorly lit areas and overcrowded, uncomfortable
Aligning practice with policy to improve patient care 55
waiting rooms, among others.1 Violence is also more likely to
erupt when facilities are understaffed, especially during meal
times and visiting hours.1
Healthcare workers are also more likely to encounter violence
when they work alone or directly with volatile people, espe-
cially if those people are under the influence of drugs or
alcohol, have a history of violent behavior or have been
diagnosed with certain psychiatric conditions.1
What can be done?
Obviously, healthcare workers canʼt control which patients
come through the doors of their facilities. They can, however,
have a strategy in place for preventing violence and effectively
halting it when it does happen.
The U.S. Occupational Safety and Health Administration
(OSHA) lists the following as the five key components in the
prevention of workplace violence2:
Management commitment and employee involvement
Management and frontline employees must work together as
a team or committee for a violence-prevention program to be
successful. Management must show concern for employee
safety and allocate appropriate resources. Employees must
comply with the workplace violence prevention program and
report violent incidents promptly and accurately.
Worksite analysis
A worksite analysis is a commonsense look at the workplace
to find existing or potential hazards for workplace violence. A
threat assessment team, patient assault team or similar task
force or coordinator can assess the vulnerability of the work-
place and determine the appropriate actions to be taken.
Hazard prevention and control
After hazards are identified through the worksite analysis,
design measures should be taken (whether through engi-
neering or administrative and work practices) to prevent and
control these hazards.
 Safety and health training
Training and education for both managers and employees
can ensure that all staff members are aware of potential
security hazards and how to protect themselves and their
coworkers. Security personnel will also need their own
specific training.
Recordkeeping and program evaluation
Recordkeeping is crucial in tracking the effectiveness of a
violence prevention program. Examples of records and
documents include the OSHA Log of Work-Related Injury and
Illness (OSHA Form 300); medical reports of work injury and
supervisorsʼ reports for each recorded assault; records of
incidents of abuse, verbal attacks or aggressive behavior that
might be threatening, information on patients with a history
of past violence, drug abuse or criminal activity; documenta-
tion of minutes from safety meetings and records of all train-
ing program, attendees and qualifications of trainers.
Employers who would like to learn more about implementing
an appropriate workplace violence prevention program
are encouraged to contact the OSHA Consultation Service
at (800) 321-OSHA. You can also learn more at www.osha.gov.2
References
1 Council on Surgical & Perioperative Safety. Statement on Violence in the Work-
place. Available at: http://www.cspsteam.org/education/education8.html/. Ac-
cessed June 19, 2008.
2 U.S. Department of Labor. Guidelines for Preventing Workplace Violence for
Health Care & Social Service Workers. Available at: http://www.osha.gov/Publica-
tions/OSHA3148/osha3148.html. Accessed June 19, 2008.
3 Carroll V. Preventing violence in the healthcare workplace. Alabama Nurse.
2004 Mar-May.
Joint Commission Targets Bullying
On July 9, 2008, The Joint Commission called for a crack-
down on bullying among healthcare professionals, noting
that such behavior poses a serious threat to patient safety
and the overall quality of care.
In a press release titled “Joint Commission Alert: Stop Bad
Behavior among Health Care Professionals,” the group
announced it will be introducing new standards requiring
more than 15,0000 accredited healthcare organizations to
create a code of conduct that defines acceptable and unac-
ceptable behaviors. These organizations will also need to
establish a formal process for managing unacceptable behavior.
The Joint Commission is recommending that healthcare
organizations take 11 specific steps to help put an end to
To view the press release in its entirety, please visit http://www.jointcommission.org/NewsRoom/NewsReleases/nr_07_09_08.htm.
56 The OR Connection
If you’re a victim
The Massachusetts Nurses Association (MNA) has
compiled a list titled “Ten Actions a Nurse Should Take
If Assaulted At Work.” Those ten actions are5:
• Get help and get to a safe area
• Call 911 for police assistance
• Get relieved of your assignment
• Get medical attention
• Exercise your civil rights, which might include filing
charges with police
• Report the assault to your supervisor
• Report the assault to your union representative
• Get counseling or assistance for Critical Incident
Stress Debriefing (CISD) to prevent post-trauma
symptoms
• Get copies of all reports and keep a diary of events
• Return to work only when you feel safe and supported
4 Cooper C, Swanson N. Workplace violence in the health sector: state of the art.
Geneva, Switzerland: International Labour Office, 2002. Available at:
http://icn.ch/state.pdf. Accessed June 19, 2008.
5 Massachusetts Nursing Association. Ten Actions A Nurse Should Take If
Assaulted at Work. Available at:
http://www.massnurses.org/health/articles/top_ten3.htm.
Accessed June 19, 2008.
bullying among physicians, pharmacists, therapists, support
staff and administrators. Among those 11 steps:
• Educate all healthcare team members about
professional behavior
• Hold all team members accountable for modeling
desirable behaviors, and enforce the code of conduct
consistently and equitably
• Establish a comprehensive approach to addressing
intimidating and disruptive behaviors
• Determine how and when disciplinary actions should begin
• Develop a system to detect and receive reports of
unprofessional behavior, and use non-confrontational
interaction strategies to address intimidating and
disruptive behaviors
 When one thinks of the operating room, phrases like
“cutting-edge technology,” “the future of medicine” and
“the newest procedures” come to mind. Although this is true,
comments like “This is how we have always done it” and “What?
Something new to learn?” are often heard as well. While these
barriers are hard to overcome, the OR of the future has many
champions, including Callie Craig, Team Manager and Periop-
erative Clinical Educator at INTEGRIS Baptist Medical
Center in Oklahoma City, Oklahoma.

Callie Craig: A Nurse Hero

By Megan Giovinco, RN, CNOR, RNFA
Callieʼs passion for perioperative nursing has been evident
throughout her eight-year tenure in surgery. She is very involved
in her facility as a member of numerous committees and councils
and was named INTEGRIS Surgery Department Nurse of the
Year in 2002.

Recruitment is one of Callieʼs primary concerns. Along with

serving as the co-chair of the Integris Nurse Recruitment and
Retention Team, she works with her facility in a variety of ways
to bring in new perioperative professionals. Callie is proud to
be a part of the many creative ways that INTEGRIS supports
both novice and experienced nurses.

As the departmentʼs educator, Callie has a great deal of

involvement with “next generation” nurses and works to

58 The OR Connection

Callie feels that the future of the
OR depends on all generations
of perioperative professionals
advocate the value they
bring to the surgical arena.
working together and learning
It was for these efforts that
she was the recipient of
AORNʼs Next Generation
Achievement Award at the from each other.
55th Congress in Anaheim
earlier this year. She was
also elected to AORNʼs National Nominating Committee, for
which she pledges to “bring my passion for perioperative
nursing and the success of [AORN].” Her passions include
not only recruitment but the promotion of overall workplace
safety, encouraging nurses to act as patient and professional
advocates and ensuring the continued growth of AORN.
Callie is certainly no new face to AORN. As a member of the
Central Oklahoma Chapter of AORN since 2003, she has
attended Congress five times, three times as a delegate. She
is also a member of the Educator/Clinical Nurse Specialist and
Leadership Specialty Assemblies. She has served as both pres-
ident and vice president of her local chapter and as a part of
the membership and nominating committees. She is also
active in the Oklahoma State Council of Perioperative Nurses
and has served as their president.
Throughout her career, Callie has sought to improve her practice
by continuing her education. She received her Certification for
Professional Achievement in Perioperative Nursing (CNOR)
and earned her BSN from the University Of Arkansas Eleanor
Mann School Of Nursing. Recently, she received her masterʼs
degree in Nursing Administration from the University of Okla-
homa Health Science Center.
Even though Callie is seen as an advocate for the next gener-
ation, she strongly believes that the “current generation” that
makes up part of the perioperative team has a great deal to
offer. Their experience and knowledge is invaluable to the staff
they work with and the patients for which they care. Callie feels
Aligning practice with policy to improve patient care 59
Special Feature
that it is just as important to
retain these perioperative
professionals as it is to
recruit new ones.
Callie feels that the future of
the OR depends on all
generations of periopera-
tive professionals working together and learning from each
other: “The new nurses and techs bring the knowledge of their
recent education and the seasoned nurses have so much ex-
perience to share. They need to get to know each other.” Cal-
lie encourages mentoring as a way for staff to learn from each
other. She credits her achievements to the support and coach-
ing she received from her own mentor, Janet Lewis, RN, MA,
CNOR, the Administrative Director of Surgical Services at IN-
TEGRIS Baptist Medical Center. As a mentor to Callie, Janetʼs
own passion for surgery was infectious. “She always said ʻcome
with me – I will show you how,ʼ” Callie recalls.
Callieʼs passion for education and helping others spills over into
other aspects of her life as well. She is a leader of Precept Upon
Precept Bible Study. She is also a member of the Council Road
Baptist Church Womenʼs Council. She continues to help the
next generation as a community volunteer for the Junior League
of Oklahoma City.
Callie has been known to quote Karen Kaiser Clark, who once
said, “Life is change. Growth is optional. Choose wisely.” Callie
has certainly chosen to grow with the changes of her profes-
sion. She believes that the opportunities are infinite in todayʼs
healthcare environment. She feels that the perioperative
professionalʼs reputation as the authority for patient and staff
safety must continue to expand as the challenges facing the
medical community as a whole are addressed. Humbly, Callie
hopes that she can be an example to other young nurses.
There is no question that she is not only an example but also an
inspiration to all perioperative professionals.
S.T.O.P. for Safety.

It could be the difference If you would like to receive a free sample

between life and death. of the S.T.O.P. Drape system to evaluate for
Wrong site surgery has recently moved into the yourself, ask your Medline representative or
number one position as the most frequently call us at 1-800-MEDLINE.
reported hospital error.1 STOP!!!
STOP!!!
Perform
P erform “TIME
“TIME O OUT”
UT”
This is despite a conscientious effort to eliminate this Verify
V erify ccorrect:
orrect:
problem before it occurs. What is needed is another layer Person
Person
Procedure
P rocedure
of safety...something that will improve our chances of Site
S ite & Side
S ide
correcting the mistake before it happens. Date:
Date: _______
_____ Time:
Time: ______
______
Surgeon’s
S urgeon’s Initials:
Initials: ______
____
Enter S.T.O.P. Surgical Drapes from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure Drape) are available in a variety of
configurations, and include a “S.T.O.P.” strip* across the
fenestration. As a result, you can’t forget to take a time
out to verify the correct patient, procedure, side and site.
Then all that is left is to hand the sticker off to the circulating
nurse to include in the medical record, documenting that
the verification process was completed. S.T.O.P. strip and sticker

References
1 The Joint Commission. The Statistics page. Available at: http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-

DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

By Brian Tracy
The greatest obstacle to success
The fear of failure is the single greatest obstacle to success in
adult life. Taken to its extreme, we become totally preoccupied
with not making a mistake, with seeking for security above all
other considerations. The experience of the fear of failure is in
the words of “I canʼt,” “I canʼt.” We feel it in the front of the body,
starting at the solar plexus and moving up to the rapid beating of
the heart, rapid breathing and a tight throat. We also experience
this fear in the bladder and in the irresistible need to run to the
bathroom.
The fear of rejection holds you back
The second major fear that interferes with performance and
inhibits expression is the fear of rejection. We learn this when our
parents make their love conditional upon our behavior. If we do
what pleases them, they give us love and approval. If we do some-
thing they donʼt like, they withdraw their love and approval –
which we interpret as rejection.
The roots of a Type A behavior
As adults, people raised with conditional love become preoc-
cupied with the opinions of others. Many men develop Type
A behavior that is characterized by hostility, suspicion and an
obsession with performance to some undetermined high stan-
dard. This is expressed in the attitude of “I have to,”
“I have to,” and is associated with the
feeling that “I have to work harder and
accomplish more in order to please
the boss” who has become
a surrogate parent.
Aligning practice with policy to improve patient care 61
Caring for Yourself
The most common trap
More than 99 percent of adults experience both these fears of
failure and rejection. They are caught in the trap of feeling,
“I canʼt,” but “I have to,” “I have to,” but “I canʼt.”
The key to peak performance
The antidote to these fears is the development of courage,
character and self-esteem. The opposite of fear is actually love,
self-love and self-respect. Acting with courage in a fearful situa-
tion is simply a technique that boosts our regard for ourselves to
such a degree that our fears subside and lose their ability to
affect our behavior and our decisions.
Action exercises
Here are two things you can do to increase your self-esteem and
self-confidence and overcome your fears.
First, realize and accept that you can do anything you put your
mind to. Repeat the words, “I can do it! I can do it!” whenever you
feel afraid for any reason.
Second, continually think of yourself as a valuable and important
person and remember that temporary failure is the way you learn
how to succeed.
Reprinted with permission from www.mercola.com.
 How to Thrive in
a Tough Economy
Unless you are on another planet, it is likely that your organization has already gone
through several “downsizings” or “rightsizings,” as your boss might like to call them.
Time to get depressed, right? Wrong!

By Wolf J. Rinke, PhD, RD, CSP

62 The OR Connection

Time to put yourself in the driverʼs seat of your career by
developing new skills that will enable you to take advantage
of the opportunities that are unfolding before your very
eyes – opportunities that will enable you to not only survive,
but thrive in this tough economy.
Think projects
Old organizations were organized by departments and
position titles. Today, projects accomplish most work. To
thrive in a project environment, recognize that work gets
done primarily by three distinct specialties. First, there are
the resource providers. These are the folks who develop
and supply talent or money. Your human resource manager
Aligning practice with policy to improve patient care 63
Special Feature
and financial officer would fit into this category. Next are the
project managers. They are responsible for making sure
that the talent and resources are organized in such a way
that the project gets done. Next is the talent. These are the
people who have the skills to get the job done, such as
nurses, OR techs and other front-line healthcare profes-
sionals. To thrive in this tough economy, it is important that
you master “winning management” skills so that you can
perform equally well in the project manager or resource
provider role. (For details read my Winning Management:
6 Fail-Safe Strategies for Building High-Performance
Organizations book.)
Think global
Globalization is accelerating at a nanosecond pace. To take
advantage of globalization, you must dramatically increase
your cultural awareness. If you are now employed in a
primarily “homogeneous” organization and are not at least
90 percent satisfied, seek employment in a multicultural
organization. Donʼt know where to start? Get a copy of
Fortuneʼs latest issue of either 100 Best Companies to Work
For (typically published in February) or Americaʼs Most
Admired Companies (typically issued in March of every
year) and apply to any of the companies listed. Want to stay
in health care? Not a problem, there are many on either list.
For example, Methodist Hospital System is in the number
10 spot on the 2008 100 Best Companies to Work For and
Manor Care is in the number one spot for the Healthcare
Medical Facilities Group in the 2008 Americaʼs Most
Admired Companies.
Equally important, learn a foreign language. If youʼre not
fluent in at least one foreign language, you will be in trouble
 IN THIS TOUGH ECONOMY
real soon. And put your language you can simply no longer expect to be Think of yourself
to work by traveling to a country compensated for time, only for results as self-employed
that speaks the language of in- Seeing yourself working for
terest to you. Youʼll really learn to and problems solved. one company for the rest of
speak it, become culturally sen- your career is, to say it gently,
sitive whether you want to or not crazy! Itʼs just not going to
and will bring back a ton of great ideas to accelerate your happen! In this tough economy, itʼs important that you see
success curve dramatically. yourself as “self-employed,” or “renting” your services out
to someone else (your employer). To get started, pretend
Become an effective team player and leader that you are an entrepreneur or a consultant who is selling
Like it or not, teams are the way lots of work is being services to a client (your employer). To make this realistic,
accomplished in todayʼs organizations. Being effective in compute your daily compensation. Be sure to add about 30
this environment requires that you learn how to empower percent for benefits. Then get in the habit of asking yourself
others and master leadership and winning management “Have I created value today that exceeded my daily com-
skills, and be equally comfortable and effective in a pensation?” Repeat that question every day you are at
supportive role as in a leadership role. (For more, read my work. You may even find it helpful to place a nice-looking
Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways sign on your work station that asks “How are you creating
to Improve Your Leadership Effectiveness book.) $_____ of value today?”

Focus on delivering exceptional quality service
Delivering exceptional quality service is not an option, but
rather a survival strategy. We must be absolutely clear
about who provides us with our paycheck. No, itʼs not your
boss or even your organization. It is the person you serve –
an external or internal “customer.” As a litmus test of how
customer-focused you are, look back at your calendar for
the last week to find our how much actual time youʼve spent
with your external or internal customers. If you are not
spending at least one third of your time with your “cus-
tomers,” you are messing up.
The other side of the coin is to keep asking “How have I
ʻgrownʼ in my job today?” To make this happen, think of
going to work each day with a “briefcase” of skills and com-
petencies. At the end of the day, check your briefcase to see
if there is more in it than at the beginning of the day. If, day
after day, what you bring to work is the same as what
you take home, itʼs is time to move on to a more challeng-
ing “assignment.”
Get in the habit of asking yourself,

Become a problem solver

One of the best ways to position yourself for advancement
or pay increases is to become a problem solver. In this
tough economy, you can simply no longer expect to be com-
pensated for time, only for results and problems solved. So
actively look for a problem that impacts negatively on the
bottom line then put a team together and solve it. Then, let
others know (especially the powers-that-be) what a great
job your team did and how much your team improved the
profitability of your organization. If you do that consistently,
you will be ready to be promoted or negotiate for an
increase in pay. (If youʼd like help with that, devour my
Win-Win Negotiation CPE program.)
“Have I created value today that
exceeded my daily compensation?”
Become an expert networker
One of the most powerful skills you can develop is to
become a highly effective networker, both inside and outside
of your organization. When it comes time to find a new
assignment, your network, more than anything else, will
determine how fast youʼll find your next dream job. To test
your networking effectiveness, ask yourself who you have
been eating lunch with during the past week. If it is pretty
much the same people, you are missing tremendous net-
working opportunities. Get in the habit of eating lunch with

64 The OR Connection
different people three out of five days a week, to sit with people
you donʼt know at meetings and to attend conferences that
are sponsored by groups other than yours.

Check yourself
To assess how well you are achieving a competitive advantage
in this tough economy, ask yourself the following diagnostic
questions:
ASK YOURSELF...
Am I learning?
If you are not constantly learning new things, your value in
• Am I learning?
the marketplace is diminishing rapidly. • Am I being taken advantage of?
Am I being taken advantage of?
• If my job was open today,
Your employer is taking advantage of you if you consistently would I get it?
sacrifice your long-term development to put out short-term
“fires.” Donʼt let your ego get the better of you when you are
• Am I adding value?
being told that you are so critical to the organization that “we • Am I good at selling?
canʼt do without you.” Hogwash! No one is indispensable.
Never, ever get caught in persistent short-term traps at the
• Am I energized by change?
expense of your long-term development. • Does my résumé focus
If my job was open today, would I get it?
on contributions?
Itʼs important that you “benchmark” your skills all of the time.
Continued on Page 36

Aligning practice with policy to improve patient care 65

Small in size.
Big on safety.

Sometimes smaller is better! The transthermal backing on 9100 Series electrosurgical pads
provides a barrier of moisture; it is waterproof and fluid resist-
At just 15 square inches, the Medline Universal Pad with propri-
ant. The backing allows heat to escape 25% faster than the
etary Safety Ring meets the same thermal performance stan-
foam traditionally used on grounding pads, reducing the risk of
dard as traditional electrosurgical pads up to 33% larger in
excessive heat buildup.
conductive surface area.

For more information on the impact the Universal

Despite its smaller size, this pad is big on safety. The propri-
Pad 9100 Series can have in your OR, contact your
etary Safety Ring allows the pad to be oriented in any direction
Medline sales representative or call 1-800-MEDLINE.
and also reduces corner and edge effect by more uniformly dis-
persing electrosurgical current over the entire conductive
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Electrosurgical Pad
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
One way to do that is to look at the want ads to find out what liberate and empower you. Action will get you to grow,
the marketplace is looking for. If you do not possess the change and adapt. Action will provide you with virtual job
skills that the marketplace is looking for, itʼs time to invest security, will enable you to achieve the competitive advan-
more in yourself. tage and assure that you thrive in this tough economy.

Am I adding value?
How long does it take you to answer this question? If you
are unable to answer it immediately, in fewer than two or
three sentences, you can assume that no one else knows
how you contribute value either. In that case, you are a likely
target during the next downsizing.

Am I good at selling?
Many healthcare professionals see no need to become
excellent at selling. The reality is that you sell all the time.
You sell your patient on getting better, you sell your boss on
a raise and you sell your team members on an idea. In
addition, you do the same at home with your spouse, children
and even your pets. Since it is something you do all of
the time, I recommend that you get good at it. No, wait, I
recommend you get great at it! So start looking for a quality
sales program and attend it this year!
Am I energized by change?
If you are still fighting or resisting change, you are in trouble.
All indications are that change will continue to accelerate at
“hyper speed,” so you might as well start welcoming it.
About the author
Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar
leader, management consultant, executive coach and editor
of the free electronic newsletters Make It a Winning
Life and The Winning Manager. To subscribe, go to
www.WolfRinke.com. He is the author of numerous books,
CDs and DVDs including Winning Management: 6 Fail-Safe
Strategies for Building High-Performance Organizations and
Donʼt Oil the Squeaky Wheel and 19 Other Contrarian
Ways to Improve Your Leadership Effectiveness, available
at www.WolfRinke.com. His company also produces a wide
variety of quality pre-approved continuing professional
education (CPE) self-study courses available at www.easy
CPEcredits.com. Reach him at WolfRinke@aol.com.

Does my résumé focus on contributions?

Finally, to check how focused you are on contributions, get
out your résumé and check for specific outcomes, specific
impact on the organization and variety and content of work,
projects and leadership experiences. Are you impressed?
Would you hire this person? If so, congratulations!

The most important concept

of all time: Take action
There is one more skill that you need to master. This one is
more important than all the others. Itʼs the one skill that,
when all else fails, will determine whether you will thrive in
this tough economy. The skill is to take action! Action lets
you know whether what youʼve tried works. If it does, do
more of it. If it does not, try something else and start the
same process all over again. Soon youʼll find yourself suc-
ceeding faster than you have ever thought possible. And
whatever you do, avoid fretting about having failed – there
is no such thing, unless you make the same mistake over
and over again. Action gets you away from bemoaning
change and mourning the lack of job security. Action will

Aligning practice with policy to improve patient care 67

 Special Feature
Angel’s Passion for Pink
By Laura Kuhn
The OR Connection staff writer
Angel hummed to herself as she tacked a poster on the
hospitalʼs bulletin board. She heard footsteps approaching
and turned to see her coworker Mary peering over her shoulder
at the poster.
“Whatʼs that, Angel?” Mary asked. “Itʼs pretty. I like the pink
ribbons. They match the ribbon on your lab coat!”
“Iʼm hosting a meeting for staff members to remind them how
important it is to conduct monthly breast self-exams,” Angel
explained. “Can I count on you to be there?”
“You bet!” Mary replied. “Iʼll even bring some cookies.” She
headed off down the hall to visit her next patient.
Angel smiled as she smoothed out the corners of the poster.
She was known for tirelessly campaigning for breast cancer
education, but very few people knew what had drawn her to
68 The OR Connection
the cause. She planned to reveal that at the meeting the
next day.
Thanks to Angelʼs posters and word of mouth, the meeting
room was filled to capacity. True to her word, Mary arrived
bearing a tray of cookies. At the podium in the front of the
room, Angel was nervously shuffling a stack of note cards.
She had written down what she planned to say, but as her
coworkers took their seats and started looking expectantly at
her, she decided to place her notes in her pocket and simply
speak from her heart.
“Hi, Iʼm Angel, and I know most of you,” she said. “You might
have noticed that I spend a lot of time promoting education
about breast cancer, and encouraging you to do monthly self-
exams. What you might not know is why I care so much.” She
took a deep breath and steadied her voice.
“When I was a sophomore in college, my mother was diag-
nosed with breast cancer. I spent the next six months, what
were ultimately the last six months of my motherʼs life, at her
side. I was there when she was wheeled out of surgery after
a double mastectomy. I was there when chemo caused her
beautiful hair to fall out all over her pillow. And I was there
when she admitted to her doctor that she had never done a
breast self-exam.
“My mother didnʼt know how to perform a self-exam, and she
wasnʼt comfortable with the idea. She didnʼt know that there
could be outward signs of breast cancer, such as change in
the size or shape of the nipple. She didnʼt know that dimpling
or puckering could be signs of an underlying problem.
“My mom didnʼt know these things, just as a lot of people
donʼt understand the full scope of how serious a problem
breast cancer still is. Weʼre making advances in early detec-
tion and treatment, but this disease is by no means going
away. In fact, more than 1.1 million women throughout the
world will be diagnosed with breast cancer this year, and
more than 410,000 of those women will die.”
Angel looked around the room and saw that the faces of
many audience members had turned grim. She needed to
inspire them, and fast!
Stay tuned for the continued adventures
of Medline’s family of nurse dolls, Angel,
Aurora, Anastasia, Ami and Alice!
Alice
Aligning practice with policy to improve patient care 69
“But thereʼs good news, too,” she continued. “Today, some-
one who is diagnosed with breast cancer in its earliest stages
has a 98 percent chance of living. That rate was only 77
percent in 1982. And education is helping to emphasize the
importance of screening, early education and the need for
more research.”
Angel grabbed for the stack of pamphlets she had brought
with her and began to hand them out. “These tell you how to
perform a breast self-exam and give you more information
on ways you can help spread the word,” she said. “Please,
take a bunch of them! Give them to your friends, your family,
your patients.” She was encouraged to see that the members
of the audience were taking four or fivepamphlets as they
were passed along.
She made her way back up to the front of the room to finish
speaking. “Thank you so much for coming to this meeting. I
lost my mother to breast cancer, and Iʼll miss her every day
of my life. With your help, though, we can prevent someone
else from experiencing that same agony. Education is truly
the key. Together, we can save lives through early detection.”
Angel smiled and was thrilled to see smiling faces looking
back at her.
Aurora Anastasia Ami
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Medline is a registered trademark of Medline Industries, Inc.

Medline Supports Breast Cancer
Awareness 365 Days a Year
Together We Can Save Lives Through
Early Detection Breast Cancer Campaign
Every three minutes a woman in the United States is
diagnosed with breast cancer. The chance of developing
invasive breast cancer at some time in a woman's life is
about 1 in 8.¹ These are startling statistics, but behind these
numbers are people — sisters, daughters, mothers, grand-
mothers, neighbors and friends. Any one of the 182,460
women who will be diagnosed with invasive breast cancer
this year could be someone we love. Although mammo-
grams are among the best forms of early detection, more
than 13 million American women over the age of 40 have
never had one.2 The Centers for Disease Control recommend
that women begin having yearly mammograms at age 40.
These facts form the foundation of Medlineʼs “Together We
Can Save Lives through Early Detection” campaign. Medline
is on a mission to change the future by taking action now.
2008 marks the third year that Medline has partnered with
the National Breast Cancer Foundation (NBCF), which
provides grants to hospitals and healthcare organizations
that offer free mammograms for underprivileged women. To
date, Medline has donated $350,000 to the NBCF to give
back to customers and their communities, help promote
early detection of breast cancer and ultimately save lives.
Spreading the word
To keep early detection on everyoneʼs minds, Medline
sponsors a number of outreach projects throughout the
year and distributes several products and programs to
promote awareness.
AORN breakfast forum
In March, Medline hosted a breakfast forum for 900 periop-
erative nurses at the annual meeting of the Association of
periOperative Registered Nurses (AORN) in Anaheim, Calif.
Featured speaker, Dr. Marla Shapiro, author of Life in the
Balance: My Journey with Breast Cancer and renowned
Canadian on-air medical expert, delivered a dynamic pres-
entation on coping with stress, balancing life and battling
breast cancer. Visit www.medline.com/aorn/2008 to learn
more about the event.
Aligning practice with policy to improve patient care 71
Caring for Yourself
Beyond the Shock® DVD
Medline, in partnership with the NBCF, distributes free
copies of the DVD “Beyond the Shock,” a step-by-step guide
to understanding the diagnosis of breast cancer. More than
70 leading oncologists contributed to the content. To request
a copy, contact Jennifer Freedman at (847) 643-4358 or
jfreedman@medline.com.
Angel doll
Angel, the second-born in Medlineʼs family of nurse dolls,
promotes infection prevention and she also sports pink
scrubs and a pink ribbon to support breast cancer awareness.
The Angel doll is distributed by Medline at trade shows and
large customer events.
Pink ribbon products
Medline sells several pink ribbon products, including a
Breast Cancer Awareness Rollator and bath bench, a pink
ribbon lab coat and special scrubs available on
scrubs123.com. A customerʼs purchase of these products
supports Medlineʼs partnership with the NBCF. Visit
medline.com or scrub123.com or contact your Medline
sales representative for more information.
For more information on Medlineʼs breast cancer
awareness campaign, visit www.medline.com/bca
or contact Jennifer Freedman at 847-643-4358 or
jfreedman@medline.com
References:
1. American Cancer Society. Cancer Reference Information. “What Are the Key
Statistics for Breast Cancer?” Available at: http://www.cancer.org/docroot/
CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp.
Accessed July 15, 2008.
2. The Breast Cancer Site. About Breast Cancer page. Available at:
http://www.thebreastcancersite.com/clickToGive/boutbreastcancer.faces?siteId
=2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.
 Caring for Yourself

Ease the Discomfort of PMS

You're feeling bloated and irritable all at the same time. Sound familiar?
You're probably having premenstrual syndrome (PMS). Up to 85 percent of
menstruating women have at least one PMS symptom as part of their
monthly cycle, according to the American College of Obstetrics
and Gynecologists.

The emotional and physical symptoms, which usually occur in the week or
two before your period, can range from mild to severe. Symptoms vary from
person to person and may include:

• Irritability or mood swings

• Tension or anxiety
• Acne
• Breast swelling and tenderness
• Tiredness
• Insomnia
• Bloating
• Depression
• Digestive problems
• Headaches
• Joint or muscle pain

Often, symptoms go away after your period starts.

Try these tips

If you think you have PMS but want to find out for sure, keep track of your
symptoms on a calendar for a couple of months. Note their severity and the
date your period starts. Then, show your doctor the calendar and your notes.

The cause of PMS remains unclear, but you may be able to ease symptoms
by following these self-care tips from the U.S. Department of Health and
Human Services:

• Take a daily multivitamin with 400 micrograms of folic acid and a

calcium supplement with vitamin D.
• Exercise regularly. For safety's sake, first check with your doctor.
• Eat a healthful diet that includes plenty of fruits, vegetables and
whole grains.
• Avoid salt, sugary foods, caffeine and alcohol.
• Try to get eight hours of sleep every night.
• Don't smoke.

Lifestyle changes alone may not bring relief if you have severe symptoms.
If this is the case, your doctor may suggest an over-the-counter pain
reliever or other medicines.

Reprinted with permission from United Healthcare

72 The OR Connection
 Healthy Eating

Holy Guacamole!
You can make this avocado salad smooth
or chunky depending on your preference.

Nutritional Information
Prep time 10 minutes Servings Per Recipe: 4
Guacamole (4 servings)

Ready in 10 minutes Amount Per Serving

Calories: 264
3 avocados - peeled, pitted and mashed Total Fat: 23.3g
1 lime, juiced Cholesterol: 0mg
1 teaspoon salt Sodium: 601mg
1/2 cup diced onion Total Carbs: 16.4g
3 tablespoons chopped fresh cilantro Dietary Fiber: 8.8g
2 roma (plum) tomatoes, diced Protein: 3.7g
1 teaspoon minced garlic
1 pinch ground cayenne pepper (optional)
www. allrecipes.com
In a medium bowl, mash together the avocados, lime juice
and salt. Mix in onion, cilantro, tomatoes and garlic. Stir in
cayenne pepper. Refrigerate 1 hour for best flavor, or serve
immediately.

Aligning practice with policy to improve patient care 73

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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
 FORMS & TOOLS

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

Electrosurgery
Electrosurgery Checklist..............................76
Electrosurgical Cautery Safety
Policy and Procedure ..................................78

Policy and Procedure ..................................81

Pressure Ulcer Prevention

Patient Safety
Surgical Safety Checklist........................86

Employee Safety
Management/Employee Checklist ..........89
Employee Incident Report ......................90

Aligning practice with policy to improve patient care 75

 Forms & Tools Electrosurgery Checklist 1
Electrosurgery Checklist
Preoperative Precautions and Procedures
Physical Condition
 Examine the ESU and its accessories for defects—
do not use cables or accessories with damaged
(cracked, burned, or taped) insulation or connectors.
 Confirm that the ESU has been inspected for safety
and performance by a qualified BMET or clinical
engineer and that the next inspection is not yet due.
Return Electrode Contact Quality Monitor
(RECQM) or Cable Continuity Alarm
 Check the operation of the RECQM or the return
electrode cable continuity alarm by attempting to
operate the unit with the dispersive electrode
disconnected—the unit should not activate, and a
tone should sound.
Audible Activation Indicator
 Activate the unit using each footswitch and
handswitch, and verify that the audible activation
tone is loud enough to be heard over other noises in
the OR.
 Verify operation of any other alarms or
protective features.
Safety Holster
 Position a safety holster for the active electrode in a
convenient location.
Dispersive Electrode
 Use a full-surface adhesive electrode.
 Inspect the electrode before placement for any flaws
or damage (e.g., discoloration, insufficient amounts
of conductive adhesive).
 Confirm that the electrode's expiration date has
not passed.
 Clean, shave, and dry the application site.
 Follow the manufacturer's recommendations for appli-
cation, and ensure firm contact of the electrode with
the skin.
 Do not apply the electrode to areas where pressure is
applied to the patient (e.g., underneath the patient).
76 The OR Connection
 Do not overlap sections of the electrode (e.g., when
applying around a small limb).
 When possible, place a long edge of the electrode
closest to the surgical site.
 If possible, do not place the dispersive electrode (or
active electrode) cables near internal pacemaker leads.
Alternate Sites
 Eliminate patient contact with grounded objects
whenever possible.
 If possible, remove nonvital monitoring electrodes
(e.g., esophageal and rectal probes).
 Keep ECG and other monitoring electrodes as far
as possible from the surgical site and the active and
dispersive electrode cables.
 Do not use needles as monitoring electrodes (these
increase the risk of alternate site burns due to higher
current density at the electrode site).
Prepping Agents
 Avoid using flammable prepping agents or other
flammable fluids (e.g., acetone degreaser).
 Avoid accumulating pools of fluids, especially near
patient electrodes.
Sparking the Active Electrode
 Do not spark the active electrode to ground or to the
dispersive electrode to test the ESU.
Intraoperative Precautions and Procedures
 Minimize buildup of O2 and N2O beneath drapes and
in the oropharynx.
 Activate the unit after vapors from flammable prepping
solutions and tinctures (if used) have dissipated.
 Activate the unit only when ready to deliver electrosur-
gical current and only when the active tip is in view;
avoid prolonged activation.
 Use the lowest effective ESU output setting; do not
continue to increase power settings if you aren't
getting results—look for other problems (e.g., confirm
adequate placement of the dispersive electrode,
check all cable connections).
 Electrosurgery Checklist 1
 Check contact and adherence of the dispersive
electrode each time the patient is repositioned.
 Always place the active electrode in a safety holster
when not in use.
 Allow only the user of the active electrode to activate
the handswitch or footswitch.
 Do not use two active electrodes on ESUs that
produce simultaneous activation of both electrodes
when only one switch is activated.
 Document every procedure in the OR record; include
the ESU identification number, ESU settings used
(monopolar cutting and coagulation, bipolar), location
of the dispersive electrode, and the condition of the
skin at the dispersive electrode site before and after
the procedure.
 Document use and position of any other equipment
(including identification numbers) used during the
procedure (e.g., hypo-/hyperthermia unit, tempera-
ture probes).
Postoperative Precautions and Procedures
 Inspect the patient for injuries at the dispersive
electrode and other sites (e.g., the sacral area—
electrosurgical injuries typically appear immediately
following the procedure; pressure injuries may not
show up for as long as one or two days following
surgery).
 Document all findings.
 If any problems are noted during or after the
procedure, save all disposable items and their
packages (so that expiration dates can be confirmed).
Courtesy of Medical Device Safety Report (MDSR) ECRI Institute, 2008.
Aligning practice with policy to improve patient care 77
Forms & Tools
Regarding “Checklists...”
Worldwide, the WHO aims to have the checklist oper-
ating in 2,500 hospitals in the most populous countries
(with 75 per cent of the world's population) by the end
of next year.
Since the 1930s, airplane pilots have run through
checklists before taking off. Now the World Health
Organization wants surgeons all over the globe to use
them, too.
Dr. E. Patchen Dellinger, a surgeon at the University of
Washington Medical Center in Seattle, says people
are surprised when he tells them about the project.
"One of the common reactions is, 'You mean you
weren't doing that before? Good heavens!'"
he says.
Gawande says there's been some resistance to the
list. One London surgeon thought it was demeaning
"Mickey Mouse stuff" until one day in the operat-
ing room.
"Right before the incision [the medical team] took a
timeout," Gawande says, "and when it came to the
nurse's turn to raise any concerns, the nurse asked:
'Are we really sure we have the right size knee
replacement for this patient?'"
Turns out, they didn't — not anywhere in the hospital.
That surgeon now swears by the surgical checklist.
 Forms & Tools Policy and Procedure
Electrosurgical Cautery Safety
PURPOSE:
To provide for the safe operation of electrosurgical units, used
for the purpose of cutting and coagulation of body tissue with
a high frequency electrical current during surgical procedures.
EQUIPMENT:
 Electrosurgical Generator
 Electrosurgical Grounding Pad
 Electrosurgical Active Electrode (Pencil)
POLICY:
 All electrosurgical generators shall meet the
performance and safety standards of the hospital.
– All electrosurgical units must be approved by the
hospital Biomed.
– Only electrosurgical units which are UL approved
shall be used in the operating room.
– Surgical Services personnel are provided with
detailed instructions from the electrosurgical unit's
manufacturer. Operational directions are attached
to each electrosurgical unit.
– Surgical Services personnel are evaluated annually
on the safe competency form use of the
electrosurgical unit and its components.
– The electrosurgical unit generator is inspected
yearly by the hospital Biomed. Dates of inspection
are posted on units. Each electrosurgical unit
generator is assigned an ID number.
– The electrosurgical unit is properly grounded,
mounted on a stand, easily cleaned and movable.
– The electrosurgical unit generator shall be kept
clean and protected from spills.
– The electrosurgical unit footswitch shall be designed
for easy cleaning, shall be shock-resistant and
designed to minimize unintentional activation.
– The electrosurgical unit footswitch cord shall be long
enough to reach the user without stress.
– Before each use, the electrical cord, connections,
plug and foot switch cord shall be inspected for
damage. The unit shall be removed from service
if damaged.
– Before each use, the electrosurgical unit safety
features (lights, activation sound, etc.) shall
be tested.
– Power settings for coagulation and/or cutting shall
be as low as possible for each procedure, confirmed
orally with the surgeon before activation and
determined according to manufacturer recommen-
dation. Activation tones are not to be turned off or
adjusted to a lower setting. (The activation tone on
newer models cannot be turned off or adjusted.)
78 The OR Connection
– Before each electrosurgical unit use, the operative
field shall be inspected for alternate ground points.
Personnel and/or patients may be injured, if the
current does not follow the designated path. Isolated
patient EKG lead units shall be used. The patient
shall not be in contact with metal table parts.
– The patient's skin integrity shall be evaluated before
and after electrosurgical use. Particular areas to
observe are under the electrode, under EKG leads,
temperature probe entry sites and positional
pressure points.
– The dispersive electrode, cord and pad, and the
active electrode and cord shall be retained for use
during the investigation of an adverse post-op
skin reaction.
 The Electrosurgical Ground Pad
(Dispersive Electrode):
– Only disposable dispersive electrodes evaluated
by the hospital Biomedical Engineer, are to be
used in the Surgical Services Department.
– The dispersive electrode shall be inspected before
each use for wire breakage or fraying. All connec-
tions shall be intact and clean.
– The dispersive electrode shall be long enough and
flexible enough to be placed on the patient without
stress on any connection.
– The dispersive electrode cord shall fasten directly
into a labeled, stress-resistant receptacle on the
electrosurgical unit.
– The dispersive electrode pad shall be placed on
the patient, on clean dry skin over a large muscle
mass, as close to the operative site as possible.
Bony prominences, hairy surfaces, and scar tissue
shall be avoided.
– Do not put the dispersive electrode pad over a
patient's tattoo.
– Do not put the dispersive electrode pad on the
patient's skin over a metal prosthesis.
Dispersive electrode and placement which restricts
blood flow shall be avoided.
– All dispersive pads shall maintain uniform body
contact. Potential problems include tenting, gaping
and liquids interfering with adhesion.
– Use pediatric electrosurgical ground pad according
to weight limit.
– The pad placement area shall be charted on the
Intraoperative Nursing Record and Nurses' Notes.
 Policy and Procedure Forms & Tools

 The Electrosurgical Active Electrode (Pencil): Based upon the policy and procedure used at Stonewall
– Only electrosurgical active electrodes approved by Jackson Memorial Hospital in Lewis County, West Virginia.
the hospital Biomedical Engineer are to be used in
the Surgical Services Department.
– The active electrode shall be inspected at the field
for damage before each use.
– The active electrode shall fasten directly into a
labeled, stress-resistant receptacle on the
electrosurgical unit.
– The active electrode cord shall be long enough
and flexible enough to reach the operative site and
the generator without stress.
– The active electrode cord shall be free of loops,
twists and metal clamps that can deviate
current flow.
– The active electrode and cord shall be inpervious
to fluids.
– The active electrode tip shall be secure and free of
charred tissue. Use a moist sponge to clean
the tip.
– The active electrode will be placed in a holster at
all times, when not in use.

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 Remedy™ is nutrition for your skin.
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Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Pressure Ulcer Prevention

Personnel: All accountable for patient care
Patient outcomes:
1. Maintenance of intact skin in the patient who is at risk for breakdown.
2. Patient/caregivers verbalize knowledge of pressure ulcer risk factors, assessment,
prevention and early treatment.

High Risk Diagnoses: Factors That Contribute To Pressure

Ulcer Development

 Peripheral Vascular Disease  Age greater than 75

 Myocardial Infarction  Existing pressure ulcer
 Stroke  Immobility
 Multiple Trauma  Those having a procedure
 Musculoskeletal which immobilizes them for
disorders/Fractures greater than one hour
 GI Bleed  Bed linen
 Spinal Cord Injury  Devices (e.g., oxygen tubing,
 Paraplegia splints, TEDs stockings)
 Neurological disorders (e.g.,  Sedation
Guillain Barré, multiple  Sensory deficits
sclerosis)  Nutritional deficits/Weight loss
 Those with unstable and/or  Excessive exposure to
chronic medical conditions (e.g., moisture (e.g., incontinence,
diabetes, renal disease, cancer) excessive perspiration, wound
 History of previous pressure drainage)
ulcer  Those exposed to friction and
 Preterm neonates shearing

Early and ongoing assessment of patients at risk for skin breakdown is essential.
Prevention involves not only identification of patients at risk but also a detailed plan
of interventions which address and minimize the effects of each risk factor.

Aligning practice with policy to improve patient care 81

 Forms & Tools Pressure Ulcer Prevention Policy and Procedure
Nursing Diagnosis
Asessement/evaluation
1. Identify patients at risk for developing a
pressure ulcer upon admission and daily for
at-risk patients or with any change in condition.
2. Assess specific vulnerable pressure points.
A. Supine: occiput, sacrum, heels
B. Sitting: ischial tuberosities, coccyx
C. Side-lying position: trochanters
D. Reddened areas which do not fade within
30 minutes
E. Dusky or cyanotic areas
F. Under devices (i.e., TEDs, pneumoboots,
splints, collars, tubing)
3. Assess skin for exposure to moisture from
intervals incontinence, wound drainage
perspiration.
82 The OR Connection
Interventions/key points
1. Determine an adult patient's risk for
developing a pressure ulcer by using the
Braden Risk Assessment.
A patient is considered at risk if their
Braden score is:
15-18 = Mild risk
13-14 = Moderate risk
10-12 = High risk
9 or below = Very high risk
2. Advance your patient to the next risk level in
the presence of:
A. Age over 75
B. Chronic illness
C. Hemodynamic instability (e.g., diastolic
blood pressure less than 60 mmHg).
3. Utilize the Nursing Care Plan to individualize
specific prevention interventions.
4. Initiate Pressure Ulcer Treatment Protocol at
the first sign of skin breakdown.
5. Consult WOC nurse when current plan of
care does not meet the needs of the patient.
2. Inspect the skin at least every 8 hours.
A. Avoid vigorous massage over bony
prominences.
B. Patients with dark pigmentation will
demonstrate a cyanotic area, warmth or
complain of pain over the bony prominence.
3. Cleanse and dry skin at routine intervals or
and at the time of soiling, using a low residue soap.
A. Initiate the Incontinence Protocol in the
incontinent patient.
B. Moisturize dry skin with lotion.
Pressure Ulcer Prevention Policy and Procedure
Nursing Diagnosis
4. A. Assess mobility and activity status.
B. Identify sitting status.
5. Assess nutritional status.
6. Identify factors that increase shearing, fric-
tion and/or pressure.
A. Shearing: Tissue layers sliding against each
other; e.g., sliding down in bed.
B. Friction: Skin rubbing against other sur-
faces; e.g., elbows and heels rubbing against
sheets.
C. Pressure/friction: e.g., heels resting on mat-
tress, devices such as oxygen tubing, cervical
collars, casts.
Aligning practice with policy to improve patient care 83
Forms & Tools
4. A. 1. Maintain or increase patient's level of
activity, mobility and range of motion unless
contraindicated.
2. Schedule regular and frequent turning and
repositioning at least every 2 hours (e.g.,
alternating supine, left lateral and right lateral
positions).
3. Individualize to the patient's needs based
on risk and level of mobility.
B. For sitting position in bed (head of bed
greater than 30°), cardiac chair or wheelchair:
1. Assist/instruct patient to shift weight at
least every 15 minutes.
2. Reposition at least every 30 minutes if
patient cannot independently perform
pressure relief exercises every 15 minutes.
3. Consult PT/OT for assistance in seating,
positioning and wheelchair cushion options.
5. Due to increased protein needs for healing,
consult Nutrition Services for a nutritional
assessment and plan at the earliest sign of
skin breakdown.
6. A. 1. Keep head of bed less than 30° unless
contraindicated.
2. Promote proper positioning, transferring and
turning techniques.
B. 1. Use reusable underpad, trapeze or lift
sheet to lift, not drag, patient.
2. Utilize pillows or positioning devices to
prevent skin surfaces from rubbing together.
C. 1. The immobilized patient should have heels
suspended off bed by using pillows or heel
suspension boots.
2. Heel and elbow protectors are best used for
reducing friction and should not be used for
pressure reduction.
3. Pad devices when it is not contraindicated.
 Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis
7. Assess patient/family knowledge of pressure
ulcer prevention, risk factors and early treatment.
7. A. Teach patient/family about the causes and
risk factors for pressure ulcer development and
ways to minimize risk.
B. The patient or caregiver, or both, should
understand the importance of the following:
1. Conduct regular inspection of skin over bony
prominences. (Individuals can use a mirror if
necessary to inspect their own skin.)
2. Follow appropriate skincare regimens.
3. Use measures to reduce friction/shearing.
4. Avoid vigorous massage of bony prominences
or reddened area.
5. Include routine turning, repositioning and the
use of pressure-reducing devices if patient is
confined to bed and/or chair.
6. Avoid use of donut-type devices.
7. Maintain adequate nutrition and fluid intake
and monitoring for weight loss, poor appetite or
gastrointestinal changes that interfere with eating.
8. Program for bowel and bladder management.
9. Promptly report healthcare changes and
nutritional problems to healthcare providers.

Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol.

References
Bryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000.
Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11.
Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal of
Gerontological Nursing. 2004;30(11):46-51.
Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania:
Springhouse; 2001.
Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers.
Glenview, Ill; 2003.
U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice
guideline. 1992.

84 The OR Connection
 Forms & Tools Policy Sample

Reprinted with permission.

86 The OR Connection
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 Management/Employee Checklist
Checklist: Organizational Assessment Questions Regarding
Management Commitment and Employee Involvement
 Is there demonstrated organizational concern for
employee emotional and physical safety and health
as well as that of the patients?
 Is there a written workplace violence prevention
program in your facility?
 Did front-line workers as well as management
participate in developing the plan?
 Is there someone clearly responsible for the violence
prevention program to ensure that all managers,
supervisors, and employees understand
their obligations?
 Do those responsible have sufficient authority and
resources to take all action necessary to ensure
worker safety?
 Does the violence prevention program address
the kinds of violent incidents that are occurring in
your facility?
 Does the program provide for post-assault medical
treatment and psychological counseling for healthcare
workers who experience or witness assaults or
violence incidents?
 Is there a system to notify employees promptly about
specific workplace security hazards or threats that are
made? Are employees aware of this system?
 Is there a system for employees to inform management
about workplace security hazards or threats without
fear of reprisal? Are employees aware of this system?
 Is there a system for employees to promptly report
violent incidents, "near misses," threats, and verbal
assaults without fear of reprisal?
Aligning practice with policy to improve patient care 89
Forms & Tools
 Is there tracking, trending, and regular reporting on
violent incidents through the safety committee?
 Are front-line workers included as regular members
and participants in the safety committee as well as
violence tracking activities?
 Does the tracking and reporting capture all types of
violence— fatalities, physical assaults, harassment,
aggressive behavior, threats, verbal abuse, and
sexual assaults?
 Does the tracking and reporting system use the latest
categories of violence so data can be compared?
 Have the high-risk locations or jobs with the greatest
risk of violence as well as the processes and procedures
that put employees at risk been identified?
 Is there a root-cause analysis of the risk factors
associated with individual violent incidents so that
current response systems can be addressed and
hazards can be eliminated and corrected?
 Are employees consulted about what corrective
actions need to be taken for single incidents or
surveyed about violence concerns in general?
 Is there follow-up of employees involved in or witnessing
violent incidents to assure that appropriate medical
treatment and counseling have been provided?
 Has a process for reporting violent incidents within the
facility to the police or requesting police assistance
been established?
Source: U.S. Department of Labor. Guidelines for Preventing Work-
place Violence for Health Care & Social Service Workers. Available
at: http://www.osha.gov/Publications/OSHA3148/osha3148.html. Ac-
cessed June 19, 2008.
 Forms & Tools Incident Report

Confidential Incident Report

To: ________________________________________ Date of Incident: _______________________________________

Location of Incident (Map/sketch on reverse side or attached): ______________________________________________

________________________________________________________________________________________________

From: _______________________ Phone: _______________________ Time of Incident: ________________________

Nature of the Incident ("X" all applicable boxes):

❑ Assaults or Violent Acts: ____ Type "l"____ Type "2"____ Type "3"____ Other____

❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident ❑ Contacts with Objects or Equipment

❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other

Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No

Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected: ___________________________________________

(For each person, complete a report; however, to the extent facts are duplicative,
any person's report may incorporate another person's report.)

Name of Affected Person(s): __________________ Service Date: _____________

Position: ___________ Member of Labor Organization? ❑ Yes ❑

No Supervisor: __________________ Has Supervisor Been Notified? ❑ Yes ❑ No

Family: _____________________ Has Been Notified by: ? ❑ Yes ❑ No

Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work: ____________________

Third parties or non-employee involvement (include contractor and lease employees, visitors, vendors, customers)? ❑ Yes ❑ No

Nature of the Incident

Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon
details; (5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and
reliability of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol? (were tests taken
to verify same?); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police,
fire, ambulance, EAP, family, etc.).

Previous or Related Incidents of This Type? ❑ Yes ❑ No

Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No Source: U.S. Department of

OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No
Incident Response Team: ______________________________
Team Leader: __________________________________________
Signature
Labor. Guidelines for Preventing
Workplace Violence for Health
Care & Social Service Workers.
Available at: http://www.osha.
gov/Publications/OSHA3148/osh
a3148.html. Accessed June 19,
__________________ 2008.
Date

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