- Email: [email protected]
Implementing AORN Recommended Practices for a Safe Environment of Care
CONTINUING EDUCATION Implementing AORN Recommended Practices for a Safe Environment of Care
2.2
ANTONIA B. HUGHES, MA, BSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #13523 Session: #0001 Fee: Members $13.20, Nonmembers $26.40
Ms Hughes has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire August 31, 2016.
Purpose/Goal To enable the learner to take an active role in implementing recommended practices for a safe environment of care in his or her perioperative practice setting.
Objectives 1. 2. 3. 4. 5. 6. 7.
Explain strategies for safe patient handling. Discuss elements of fire safety. Describe precautions for safe use of electrical equipment. Discuss appropriate use of clinical and alert alarms. Describe precautions to avoid thermal injuries. Explain actions to take for the patient with latex sensitivity. Describe the components of a chemical hazard risk assessment.
Conflict of Interest Disclosures
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.06.007
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RECOMMENDED PRACTICES Implementing AORN Recommended Practices for a Safe Environment of Care 2.2 ANTONIA B. HUGHES, MA, BSN, RN, CNOR
www.aorn.org/CE
ABSTRACT Providing a safe environment for every patient undergoing a surgical or other invasive procedure is imperative. AORN’s “Recommended practices for a safe environment of care” provides guidance on a wide range of topics related to the safety of perioperative patients and health care personnel. The recommendations are intended to provide guidance for establishing best practices and implementing safety measures in all perioperative practice settings. Perioperative nurses should be aware of risks related to musculoskeletal injuries, fire, equipment, latex, and chemicals, among others, and understand strategies for reducing the risks. Evidence-based recommendations can give practitioners the tools to guide safe practice. AORN J 98 (August 2013) 154-163. AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.06.007 Key words: musculoskeletal injury, fire safety, electrical equipment, clinical alarm, alert alarm, blanket-warming cabinet, solution-warming cabinet, latex, natural rubber latex, methyl methacrylate bone cement, formalin.
T n n n n n n n
he AORN “Recommended practices for a safe environment of care”1 addresses a broad range of safety topics, including
musculoskeletal injury, fire safety, electrical equipment, clinical and alert alarms, blanket- and solution-warming cabinets, medical gas cylinders, waste anesthesia gases,
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latex, n chemicals, and n hazardous waste. The recommended practices (RP) document was originally published in 1988 and has been revised numerous times. It was revised most recently in 2012 to bring AORN’s recommendations up to date with new evidence, guidelines, and regulatory changes. This updated RP document is evidence rated. Each individual reference is evaluated for strength http://dx.doi.org/10.1016/j.aorn.2013.06.007
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RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE and quality, and each intervention is rated based on the level of the supporting evidence. Although the RP documents have previously been well referenced, the strength and quality of the evidence were not always apparent to the reader. To begin the evidence review process, a medical librarian conducts a systematic literature search to locate references related to the topic, including relevant regulations and professional guidelines. The lead author and a doctorally prepared evidence reviewer evaluate each reference and assign each one an appraisal score. Then the collective evidence that supports each intervention statement is reviewed, and a rating is assigned to the intervention. The RP document has been accepted for inclusion in the Agency for Healthcare Research and Quality National Guideline Clearinghouse, a searchable database of clinical practice evidence-based guidelines and abstracts. WHAT’S NEW Based on the literature review and appraisal, the RP document was updated to reflect new evidence. Topics included in the previous iteration of the RP document have been expanded to address additional aspects of safety for patients and health care personnel. For example, Recommendation I, related to occupational injuries for health care providers, has been expanded to include examples of specific riskreduction strategies for injury prevention. Recommendation II, which addresses fire safety, now includes the practice recommendation to conduct a fire risk assessment before every surgical procedure.
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Recommendation III on the safe use of electrical equipment includes the intervention of completing regular inspections of equipment before use. In Recommendation IV, the discussion of alert alarms has been expanded and an intervention added regarding the need to communicate any change to the alarm default parameters. Recommendation V recommends precautions to take in the event of a malfunction in a blanket- or solutionwarming cabinet. The subject of latex safety has been added to the RP document in Recommendation VIII. Care of the patient with a latex allergy or sensitivity was previously addressed in the “AORN latex guideline.”2 Recommendation IX includes the requirement of conducting an annual chemical risk assessment. Other significant changes to the content of the document include deleting topics that are addressed in other RP documents. Topics previously included in the “Recommended practices for a safe environment of care” that are addressed in other RP
Educational Resources n
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AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 553-572. AORN Video Library: Electrosurgery: Function, Practice & Safety [DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all. AORN Video Library: Fire Prevention in the Perioperative Suite [DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all. AORN Video Library: Latex in the Perioperative Setting: Strategies for the Patient and Staff Safety [DVD]. http://cine-med.com/ index.php?nav¼aorn&cat¼all. Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/firesafety/. Periop 101 Module: Natural Latex Sensitivity/Allergy. AORN, Inc. http://www.aorn.org/PeriopModules/. Safe Patient Handling and Movement Tool Kit. AORN, Inc. http:// www.aorn.org/ToolKits. Workplace Safety Tool Kit. AORN, Inc. http://www.aorn.org/ ToolKits.
Web site access verified April 16, 2013.
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documents include exposure to surgical smoke3,4; exposure to chemotherapeutic agents5; incorrect tubing connections5; and requirements for heating, ventilation, and air conditioning.6 Exposure to bloodborne pathogens7 and radiation safety8 are also outside the scope of this RP document. RATIONALE Identifying safety issues is the first step in creating and maintaining a safe perioperative environment. The RP document not only identifies hazards present for health care personnel and patients but suggests risk-reduction strategies that can be put into place before a problem occurs. Emphasis is placed on assessing the environment for hazards and understanding how to correct and report safety issues. Perioperative nurses can use the RP document to help educate team members about the potential hazards in the environment and how to mitigate risk. A multidisciplinary team can use this RP document to guide development of a quality management plan and to create policies and procedures for safety in the perioperative area. DISCUSSION Because this RP addresses a broad range of safety topics, the topics discussed in this article are limited to musculoskeletal injury, fire safety, electrical equipment, alarms, blanket- and solutionwarming cabinets, latex safety, and chemicals. The full RP document should be consulted for more information on these topics and additional topics that are not included in this article. Recommendation I Perioperative team members should take precautions “to mitigate the risk of occupational injuries that may result in death, days lost from work, work restrictions, medical treatment beyond first aid, and loss of consciousness.”1(p218) A significant hazard for all health care workers is the risk of musculoskeletal injury. Working in the perioperative environment may include performing tasks that are forceful or repetitive, that require maintaining 156 j AORN Journal
HUGHES awkward or static postures, or that involve physical exertion (eg, carrying heavy equipment).9 In addition, surgical and invasive procedure rooms have cords, booms, equipment on wheels, and the potential for wet floors, all of which can present the risk of slips, trips, and falls. Perioperative personnel should consider administrative, engineering, and behavioral controls when developing strategies for injury prevention. Administrative controls include educating personnel on ergonomic and safe patient handling techniques, which can decrease overall occupational injuries.10 Engineering controls include having appropriate patient handling equipment; use of transfer devices should be the norm in the organization. An example of a behavioral control is eliminating clutter by bundling and covering cables on the floor to reduce the risk of team members tripping over exposed wires and tubes.11 The physical environment should be conducive to safety. Adequate lighting, adequate storage, and ceiling-mounted electric or hydraulic booms, when feasible, can decrease the risk of injuries to personnel.11-13 The perioperative nurse should be aware of any potential hazards in the environment and know where and how to report any deficiencies. Recommendation II “Potential hazards associated with fire safety in the practice setting should be identified, and safe practices for communication, prevention, suppression, and evacuation should be established and followed.”1(p220) Each facility should have a written fire prevention plan that is developed by a multidisciplinary team. The plan should include team members’ responsibilities, an evacuation plan, and the frequency and content of fire safety education. AORN recommends performing a fire risk assessment before each surgical procedure (Figure 1). The RN circulator initiates the fire risk assessment, during which the team pinpoints fire risks and identifies ways to mitigate those risks. The elements of the risk assessment should be shared with the
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE Fire Risk Assessment Tool A fire risk assessment is performed by the surgical team. The surgical team will assess the patient for potential fire risks: open oxygen source, available ignition source, or surgical site above the nipple line. Circle appropriate option
Yes
No
Surgical site above the xiphoid process
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0
Open oxygen source (patient receiving supplemental oxygen via any variety of face mask or nasal cannula)
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Available ignition source (electrosurgical unit, laser or fiber-optic light source)
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Total Score: 3 = High risk 2 = Low risk with the potential to convert to high risk 1 = Low risk RN circulator: Announce the risk assessment score to the other team members. Team: Follow the Fire Safety Plan according to unit-specific standards.
Figure 1. A fire risk assessment tool can be used before the start of each surgical procedure to determine whether the procedure includes a risk of fire. Printed with permission from Baltimore Washington Medical Center, Glen Burnie, MD.
entire surgical team. The communication includes identifying the use of ignition sources, potential oxidizers, and fuel sources. These three elements, which are necessary for a fire to occur, are known as the fire triangle (Figure 2). Perioperative nurses have influence over the fuel sources, which include clothing, drapes, and prep solutions. Perioperative nurses should help ensure that an ignition source does not come into contact with a fuel source.14 Examples include making sure a holster device is available to keep the electrosurgical active electrode (ie, pencil) from contacting the drapes when it is not in use and ensuring that prep solution is dry before the surgeon activates the electrosurgical device. The RN circulator and scrub person should make sure that sterile saline or water is available on the back table to douse flames if needed. Fire safety includes having clearly marked exits, hallways with good egress, and readily available fire extinguishers, as well as performing regularly
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scheduled fire drills. Participating in fire drills allows nurses and other team members to actively learn and practice what to do during a fire, where fire extinguishers are located, when to evacuate, and the best route for evacuation. A representative from the perioperative department should coordinate a drill with local fire departments after coordination with the facility’s fire safety officer. Fire drills should include a review of the exit path and how to use a fire extinguisher. The fire safety officer should conduct a post-fire drill review with the personnel who participated. The review should include a discussion about how to safely evacuate the area and protect patients. Recommendation III Perioperative team members should take precautions “to mitigate the risk of injury associated with the use of electrical equipment.”1(p224) If it is not handled and cared for correctly, electrical equipment presents a potential risk of fire or injury to patients and health care personnel.15 For example, a frayed cord or a cord separating from the plug could convey an electrical shock or start a fire. Personnel at every facility should have a mechanism in place for regularly inspecting new and existing equipment for damage periodically and before use. Perioperative nurses may be asked to participate in the inspection or to gather necessary equipment. Each facility should identify how equipment is inspected and how personnel are made aware that the inspection has been completed (eg, an updated sticker). Personnel should also assess the facility’s ability to provide the necessary power source to the equipment. For example, some equipment (eg, robotics, lasers) requires specific electrical load capabilities. Although the previous edition of this RP document recommended that use of extension cords be avoided, the new document allows for the use of electrical extension cords when appropriate. The grade of wire and type of plug should match the equipment and the facility power source. Mismatched electrical characteristics can cause AORN Journal j 157
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HUGHES any changes in the alarm parameters or tone are included in the patient hand-off communication between health care providers.19 In each organization, clinical engineering or biomedical department personnel should develop procedures for regular testing of clinical and alert alarms,17,18 and perioperative nurses should understand how the facility reviews and tests alarms. The testing may be performed at the beginning of the day or on a set schedule. Perioperative nurses also should collaborate with clinical engineering personnel to help maintain an inventory of devices with clinical alarms and track the testing of devices.
Figure 2. The AORN Fire Triangle illustrates the three elements necessary for a fire and the members of the perioperative team who frequently influence the elements. Reprinted from Perioperative Standards and Recommended Practices with permission from AORN, Inc, Denver, CO. Copyright ª 2013. All rights reserved.
damage to the equipment and overheating of the cord.15 Recommendation IV Alarms in the perioperative setting are intended to alert personnel to changes in a patient’s clinical status or to equipment malfunctions. Perioperative team members should take precautions “to mitigate hazards associated with non-functioning clinical and alert alarms or with personnel failing to hear or failing to act on alarms.”1(p225) Perioperative nurses use clinical alarm systems as an adjunct to patient care; however, The Joint Commission has identified clinical alarms as a source of potential harm for the patient if they are not checked and used appropriately.16 Clinical alarms should be set so that all personnel can hear the audible alarm over competing noise.17,18 If default parameters are changed on a clinical alarm, there must be clear verbal and visual communication among personnel about what changes were made. Perioperative RNs should help ensure that 158 j AORN Journal
Recommendation V A warm blanket may help comfort a patient and mitigate anxiety during the surgical event; however, perioperative team members should take precautions “to avoid thermal injuries related to warming solutions, blankets, and patient linens in blanket- and solution-warming cabinets.”1(p225) Thermal injuries are a potential safety hazard in the perioperative setting because patients are sedated and may not be able to communicate any discomfort from overheated linens or solutions. Warming cabinets should be labeled to identify the items that may be placed in the cabinet. An example is to label the outside of each cabinet shelf to indicate the permitted contents (eg, blankets on top, fluid on bottom).20 The temperature of each unit should be set, monitored, maintained, and documented according to organizational policy and manufacturers’ specifications. A manual log may be used if the temperature is not recorded via an electronic recording system. The temperature reading should be visible to the person retrieving the item from the warmer so he or she can verify that the item is warmed to a safe temperature. Any warmed item that is not the correct temperature when removed from the warmer (ie, is too warm or too cold) may indicate that the equipment is malfunctioning, and this should be reported to clinical engineering or biomedical department personnel.21
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE Fluid-warming cabinets should be labeled “for fluid only.” Fluid manufacturers have recommendations for temperature settings and for the length of time that fluids may be warmed safely. Perioperative nurses should label any solutions placed in a warming cabinet with the date that the solution was placed in and removed from the cabinet to help determine when the solution has reached its maximum shelf life and ensure it has not been in the warming cabinet for longer than the solution manufacturer’s recommended warming time.20 “The temperature of solutions on the sterile field should be remeasured before administration.”1(p226) Solutions intended for IV administration should be warmed only with technology specifically designed to warm these solutions because these may overheat if placed in a warming cabinet.20,22 Recommendation VIII The “AORN latex guideline”2 has been retired, and the recommendations related to latex safety have been updated and included in the current edition of the “Recommended practices for a safe environment of care.” The recommendation states, “A protocol to establish a natural rubber latexesafe environment should be developed and implemented.”1(p229) An allergic reaction to latex could cause a patient to experience anaphylaxis during a surgical procedure.23-25 In addition, health care personnel are frequently exposed to latex in the surgical environment and thus are at risk for developing latex sensitivity.26 Latex exposure may occur through contact with products containing latex or through airborne particles. Perioperative personnel should wear low-protein or powder-free latex gloves or latex-free gloves to minimize their own latex exposure.27 AORN’s latex recommendations include conducting a thorough preoperative assessment of each patient. In the assessment, the perioperative RN should address at least the patient’s history of longterm bladder care, history of multiple surgical procedures, food allergies (eg, banana, kiwi,
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avocado, chestnut, raw potato), and occupational exposure to latex. Patients with latex sensitivity or allergy should be identified with a bracelet or wristband, on the medical record, and on the patient’s bed. The patient should be scheduled as the first patient of the day, because potentially fewer latex proteins will be airborne in the OR if no other procedures have been performed in the OR that day.28 The perioperative RN can help provide the latexsensitive or -allergic patient with a latex-safe environment by gathering non-latex products, removing products that contain latex from the room, and posting signs on the doors of the OR to alert personnel that the patient has a latex sensitivity or allergy. The nurse should include a patient’s latex sensitivity or allergy in hand-off communication to other health care personnel.24 When withdrawing medication from a vial, the perioperative nurse should not remove the stopper of the vial. In a review of the literature, no evidence was found to support the practice of removing medication vial stoppers to prevent contact with latex in the stopper; the medications may already contain latex from contact with the stopper during transport and storage.25 The stopper should be punctured only once to decrease the possibility of introducing latex proteins into the medication.25 A multidisciplinary team approach should be taken in caring for patients with latex sensitivity or allergy. A member of the materials management team should review current and potential purchases of products containing latex with the clinical staff. After the products are identified, clinical personnel on the value analysis team may be able to assist with appropriate purchase selections for latex-safe products. Recommendation IX Improper handling of chemicals can result in injury to health care personnel and patients (eg, burns, eye damage, respiratory problems). As required by the Occupational Safety and Health Administration,29 health care personnel must take precautions “to AORN Journal j 159
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mitigate the risks associated with the use of chemicals in the perioperative setting (eg, methyl methacrylate, glutaraldehyde, formalin, ethylene oxide).”1(p231) The RP document provides guidance on the use of each of these chemicals. Health care organizations must follow the most stringent of the federal, state, or local regulations for chemical handling and disposal. Safety data sheets, formerly called material safety data sheets, must be readily accessible to employees within the practice setting.29 The health care organization must annually perform a chemical hazard risk assessment within the unit or facility that includes requirements for handling, storing, and disposing of chemicals and for managing spills and treating chemical exposures.29 Each perioperative health care provider has a responsibility to know how and where to seek information regarding chemicals in his or her practice setting. A hazardous chemical spill drill could be performed in addition to annual fire safety drills. The Final Four The final four recommendations in each AORN RP document discuss education/competency, documentation, policies and procedures, and quality assurance/performance improvement, as applicable. These four topics are integral to the implementation of AORN practice recommendations. Personnel should receive initial and ongoing education and competency validation as applicable to their roles. Implementing new and updated recommended practices affords an excellent opportunity to create or update competency materials and validation tools. AORN’s perioperative competencies team has developed the AORN Perioperative Job Descriptions and Competency Evaluation Tools30 to assist perioperative personnel in developing competency evaluation tools and position descriptions. Documentation of nursing care should include patient assessment, plan of care, nursing diagnosis, and identification of desired outcomes and interventions, as well as an evaluation of the patient’s 160 j AORN Journal
HUGHES response to care. Implementing new or updated recommended practices may warrant a review or revision of the relevant documentation being used in the facility. Policies and procedures should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting. New or updated recommended practices may present an opportunity for collaborative efforts among nurses and personnel from other departments within the facility to develop organization-wide policies and procedures that support the recommended practices. The AORN Policy and Procedure Templates, 3rd edition,31 provides a collection of 30 sample policies and customizable templates based on AORN’s Perioperative Standards and Recommended Practices.32 Quality assessment and improvement activities assist in evaluating the quality of patient care, the presence of environmental safety hazards, and the formulation of plans for taking corrective actions. For details on the final four practice recommendations that are specific to the RP document discussed in this article, please refer to the full text of the RP document. AMBULATORY PATIENT SCENARIO A busy, six-room outpatient surgical facility located in the Midwest routinely prepares its patients with a preoperative telephone call. The preoperative nurse asks the patient about health history, including a family history of malignant hyperthermia, and about medication and food allergies. The patient receives education related to the surgical procedure and surgeon preferences. Ms D is a 35-year-old woman scheduled for a laparoscopic umbilical hernia repair. The patient is herself a perioperative RN, and during her preoperative assessment, she tells the preoperative nurse that she has sensitivity to latex. The preoperative nurse immediately reports the patient’s latex sensitivity to the perioperative team. The RN circulator and the scrub person prepare the OR according to the surgeon’s preferences and with consideration for the patient’s latex sensitivity. They
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE post signs stating “Latex Allergy” on the OR doors to alert anyone entering the room. They examine each item carefully to determine whether it contains any latex and remove those that do from the OR, substituting latex-free alternatives. They complete the counts, and the RN circulator goes to meet Ms D. The nurse confirms the intended procedure with Ms D, and they discuss her latex sensitivity. The RN circulator explains that non-latex gloves will be used and that all of the products in the room have been inspected to make sure they do not contain latex. A nursing diagnosis includes the potential for hypothermia and retained foreign object and the need to implement latex allergy precautions. A forced-air warming device is placed on the patient before the induction of anesthesia. The counts are correct throughout the procedure. No signs and symptoms of latex allergy are noted during the procedure. The patient’s surgery is completed without complication. The RN circulator includes the information about the patient’s latex sensitivity in the hand-off report to the postanesthesia care unit nurse. The patient recovers as expected and meets all criteria for discharge to home. HOSPITAL PATIENT SCENARIO The environmental safety manager, OR manager, chief of anesthesia, and perioperative educator in an urban, mid-Atlantic community hospital plan to conduct an unannounced fire drill. The hospital safety officer notifies the local fire department and the insurance carrier with the date and time of the event. The time is scheduled as an inservice education program for personnel from the surgical and anesthesia departments; however, the
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participants are unaware that the subject of the education program will be a fire drill. On the day of the drill, perioperative personnel are separated into three rooms, and each room has an assigned leader who distributes scripts for the drill. The leader assigns each person a role (ie, RN circulator, scrub person, surgeon, anesthesia professional, nursing assistant, student) before the scenario starts. In room one, the group scenario describes a patient undergoing a tracheostomy on a patient care bed when the bed begins to emit smoke from the motor area. The leader watches how group members respond to the situation. Several team members leave the room in search of fire extinguishers and to alert the charge nurse. The leader determines that too much time lapses and declares that everyone in the room died from smoke inhalation. In room two, the group scenario describes a patient undergoing an upper body procedure when the electrosurgical device begins to shoot flames across the room. This group quickly pulls the fire box alarm and gathers up the patient to evacuate the room. They choose to leave by an old, unused loading dock exit because the exit is close
Resources for Implementation n n n
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AORN Syntegrity Framework. AORN, Inc. http://www.aorn.org/ syntegrity. ORNurseLinkTM. http://ornurselink.aorn.org. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/ JobDescriptions. Policy & Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. Ambulatory Surgery Center Resources [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/ Ambulatory_Surgery_Center_Resources.aspx
Editor’s notes: AORN Syntegrity is a registered trademark and ORNurseLink is a trademark of AORN, Inc, Denver, CO. Web site access verified April 16, 2013.
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to the main OR doors. The group members discover that they cannot bring the patient, who is on the OR bed, down the blocked ramp. The scenario ends at this point because the team is not successful in evacuating the patient. In room three, the group scenario describes a fire that develops during a surgical procedure because the electrosurgical active electrode (ie, pencil) lying on the drape is accidentally activated and ignites the drapes that are covering the patient. The group members are able to smother the flames with normal saline from the back table. They elect not to evacuate the patient because the fire has been extinguished. The drapes are removed from the patient and the patient is assessed for injury. It is determined that the patient has not been injured. The patient is re-draped and the sterile field re-established. The procedure is resumed. After all three scenarios conclude, the safety officer conducts a post-drill briefing with all involved personnel. They evaluate each scenario and highlight the weak points. In the first scenario, the patient should have been transferred quickly from the bed to a stretcher or to another OR bed. The smoking bed should have been isolated and the fire extinguished. The second group relates that they tried to evacuate, but the exit ramp was blocked, which taught the group that the loading dock exit is only safe for personnel and patients who can walk. The third group reacted the fastest to their scenario. Lessons learned from that scenario were that fire can erupt very quickly and the response must be fast to prevent harm. CONCLUSION The AORN “Recommended practices for a safe environment of care”1 encompasses a wide range of topics, and the importance of a safe environment of care is clearly outlined. Each topic in the document can have a significant effect on patient and personnel safety. Key takeaways include the following: n
Musculoskeletal injuries often can be prevented with the use of transfer devices and other measures.
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Fire safety involves the entire health care team; vigilance with each patient interaction will lead to a reduced risk of surgical fires. Health care team members should use electrical devices and components safely and correctly to avoid potential harm. Clinical alarms and alert alarms can notify personnel of a patient’s changing condition or an equipment malfunction as long as they can be heard above competing noise. Perioperative team members should know how to monitor and maintain correct temperatures in warming devices. Screening patients for latex sensitivity or allergy before surgery and using latex-safe products increases the safety of the environment. Improper handling of chemicals can result in injury to health care workers and patients. Safety data sheets must be readily accessible to health care workers for every potentially hazardous chemical in the practice setting.
The “Recommended practices for a safe environment of care” outlines how perioperative personnel should practice within the recommendations. Perioperative nurses should review the RP document with their colleagues and managers to help develop clear and comprehensive policies and procedures for their facilities. Health care workers and patients expect and deserve a safe environment.
References 1. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:217-241. 2. AORN latex guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 605-620. 3. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:125-141. 4. Recommended practices for laser safety in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:143-156. 5. Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-293.
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE 6. Recommended practices for a safe environment of care: part II. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc. In press. 7. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 8. Recommended practices for reducing radiological exposure in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:295-304. 9. Esser AC, Koshy JG, Randle HW. Ergonomics in officebased surgery: a survey-guided observational study. Dermatol Surg. 2007;33(11):1304-1313. 10. Reddy PP, Reddy TP, Riog-Francoli J, et al. The impact of the Alexander technique on improving posture and surgical ergonomics during minimally invasive surgery: pilot study. J Urol. 2011;186(4 suppl):1658-1662. 11. Cappell MS. Accidental occupational injuries to endoscopy personnel in a high-volume endoscopy suite during the last decade: mechanisms, workplace hazards, and proposed remediation. Dig Dis Sci. 2011;56(2): 479-487. 12. van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc. 2009;23(6):1279-1285. 13. AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:553-572. 14. Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol. 2008;21(6):790-795. 15. NFPA 99: Health Care Facilities Code Handbook. Quincy, MA: National Fire Protection Association; 2012. 16. Medical device alarm safety in hospitals. Sentinel Event Alert. April 8, 2013;50. http://www.jointcommission .org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF. Accessed June 13, 2013. 17. Clinical Alarms Task Force. Impact of clinical alarms on patient safety: a report from the American College of Clinical Engineering Healthcare Technology Foundation. J Clin Eng. 2007;32(1):22-33. 18. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 19. Brown JC, Anglin-Regal P. Clinical alarm management: a team effort. Biomed Instrum Technol. 2008;42(2): 142-144.
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20. Warming cabinets. Oper Room Risk Manag. 2010; 2(Surgery 7). https://www.ecri.org/Documents/RM/ ORRM_TOC/SU7ES.pdf. Accessed June 19, 2013. 21. Huang S, Gateley D, Moss AL. Accidental burn injury during knee arthroscopy. Arthroscopy. 2007;23(12):1363. e1-1363.e3. 22. Limiting temperature settings on blanket and solution warming cabinets can prevent patient burns. Health Devices. 2005;34(5):168-171. 23. Pollart SM, Warniment C, Mori T. Latex allergy. Am Fam Physician. 2009;80(12):1413-1418. 24. Mertes PM, Lambert M, Gueant-Rodriguez RM, et al. Perioperative anaphylaxis. Immunol Allergy Clin North Am. 2009;29(3):429-451. 25. Heitz JW, Bader SO. An evidence-based approach to medication preparation for the surgical patient at risk for latex allergy: is it time to stop being stopper poppers? J Clin Anesth. 2010;22(6):477-483. 26. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010; 126(3):477-480. 27. Power S, Gallagher J, Meaney S. Quality of life in health care workers with latex allergy. Occup Med (Lond). 2010;60(1):62-65. 28. Bernardini R, Catania P, Caffarelli C, et al. Perioperative latex allergy. Int J Immunopathol Pharmacol. 2011;24(3 suppl):S55-S60. 29. Occupational Safety and Health Standards. Toxic and hazardous substances: hazard communication. 29 CFR x1910.1200. Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show _document?p_table¼STANDARDS&p_id¼10099. Accessed April 9, 2013. 30. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. 31. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. 32. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013.
Antonia B. Hughes, MA, BSN, RN, CNOR, is a perioperative education specialist, Baltimore Washington Medical Center, Edgewater, MD. Ms Hughes has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for a Safe Environment of Care
2.2 www.aorn.org/CE
PURPOSE/GOAL To enable the learner to take an active role in implementing recommended practices for a safe environment of care in his or her perioperative practice setting.
OBJECTIVES 1. 2. 3. 4. 5. 6. 7.
Explain strategies for safe patient handling. Discuss elements of fire safety. Describe precautions for safe use of electrical equipment. Discuss appropriate use of clinical and alert alarms. Describe precautions to avoid thermal injuries. Explain actions to take for the patient with latex sensitivity. Describe the components of a chemical hazard risk assessment.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS 1.
Educating perioperative personnel on ergonomic and safe patient handling techniques to prevent injuries is an example of a. b. c. d.
2.
sharing the elements of the risk assessment with the entire surgical team. 4. identifying the use of ignition sources, potential oxidizers, and fuel sources. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 3.
an administrative control. a behavioral control. an engineering control. a work practice control.
3.
The element of the fire triangle that perioperative nurses most commonly have influence over is a. the fuel source. b. the ignition source. c. the oxidizer.
4.
The elements of a fire drill should include 1. the location of fire extinguishers.
A fire risk assessment performed before each surgical procedure includes 1. 2.
pinpointing fire risks. identifying ways to mitigate fire risks.
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CE EXAMINATION 2. 3. 4.
how to use a fire extinguisher. the best route for evacuation. a post-fire drill review. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
5.
Electrical extension cords may be used in the OR when appropriate as long as the grade of wire and type of plug match the equipment and the facility power source. a. true b. false
6.
Changes to the default parameters of a clinical alarm should be communicated 1. during the patient hand off. 2. to The Joint Commission. 3. verbally. 4. visually. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
7.
Perioperative nurses should label any solutions placed in a warming cabinet with the date that the solution was 1. placed in the cabinet. 2. purchased. 3. removed from the cabinet. 4. manufactured.
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a. 2 and 4 c. 1, 2, and 3
b. 1 and 3 d. 1, 2, 3, and 4
8.
Topics related to latex sensitivity that the perioperative RN should address during the preoperative assessment include 1. food allergies. 2. a history of multiple surgical procedures. 3. occupational exposures. 4. risk factors for malignant hyperthermia. a. 1 and 4 b. 2 and 3 c. 1, 2, and 3 d. 1, 2, 3, and 4
9.
Perioperative personnel should remove the stopper from medication vials before withdrawing medication to reduce the potential for contaminating the medication with latex proteins. a. true b. false
10.
The chemical hazard risk assessments should include requirements for 1. handling chemicals. 2. managing chemical spills. 3. storing chemicals. 4. treating chemical exposures. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for a Safe Environment of Care
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Explain strategies for safe patient handling. Low 1. 2. 3. 4. 5. High 2. Discuss elements of fire safety. Low 1. 2. 3. 4. 5. High 3. Describe precautions for safe use of electrical equipment. Low 1. 2. 3. 4. 5. High 4. Discuss appropriate use of clinical and alert alarms. Low 1. 2. 3. 4. 5. High 5. Describe precautions to avoid thermal injuries. Low 1. 2. 3. 4. 5. High 6. Explain actions to take for the patient with latex sensitivity. Low 1. 2. 3. 4. 5. High 7. Describe the components of a chemical hazard risk assessment. Low 1. 2. 3. 4. 5. High
8. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 9. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 10.Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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11. Will you change your practice as a result of reading this article? (If yes, answer question #11A. If no, answer question #11B.) 11A. How will you change your practice? (Select all that apply) 1. 2. 3.
4.
5.
I will provide education to my team regarding why change is needed. I will work with management to change/ implement a policy and procedure. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. Other: ________________________________
11B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. 2.
CONTENT
2.2
3. 4.
The content of the article is not relevant to my practice. I do not have enough time to teach others about the purpose of the needed change. I do not have management support to make a change. Other: ________________________________
12. Our accrediting body requires that we verify the time you needed to complete the 2.2 continuing education contact hour (132-minute) program: _________________________________
AORN, Inc, 2013
2.2
ANTONIA B. HUGHES, MA, BSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #13523 Session: #0001 Fee: Members $13.20, Nonmembers $26.40
Ms Hughes has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire August 31, 2016.
Purpose/Goal To enable the learner to take an active role in implementing recommended practices for a safe environment of care in his or her perioperative practice setting.
Objectives 1. 2. 3. 4. 5. 6. 7.
Explain strategies for safe patient handling. Discuss elements of fire safety. Describe precautions for safe use of electrical equipment. Discuss appropriate use of clinical and alert alarms. Describe precautions to avoid thermal injuries. Explain actions to take for the patient with latex sensitivity. Describe the components of a chemical hazard risk assessment.
Conflict of Interest Disclosures
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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RECOMMENDED PRACTICES Implementing AORN Recommended Practices for a Safe Environment of Care 2.2 ANTONIA B. HUGHES, MA, BSN, RN, CNOR
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ABSTRACT Providing a safe environment for every patient undergoing a surgical or other invasive procedure is imperative. AORN’s “Recommended practices for a safe environment of care” provides guidance on a wide range of topics related to the safety of perioperative patients and health care personnel. The recommendations are intended to provide guidance for establishing best practices and implementing safety measures in all perioperative practice settings. Perioperative nurses should be aware of risks related to musculoskeletal injuries, fire, equipment, latex, and chemicals, among others, and understand strategies for reducing the risks. Evidence-based recommendations can give practitioners the tools to guide safe practice. AORN J 98 (August 2013) 154-163. AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.06.007 Key words: musculoskeletal injury, fire safety, electrical equipment, clinical alarm, alert alarm, blanket-warming cabinet, solution-warming cabinet, latex, natural rubber latex, methyl methacrylate bone cement, formalin.
T n n n n n n n
he AORN “Recommended practices for a safe environment of care”1 addresses a broad range of safety topics, including
musculoskeletal injury, fire safety, electrical equipment, clinical and alert alarms, blanket- and solution-warming cabinets, medical gas cylinders, waste anesthesia gases,
n
latex, n chemicals, and n hazardous waste. The recommended practices (RP) document was originally published in 1988 and has been revised numerous times. It was revised most recently in 2012 to bring AORN’s recommendations up to date with new evidence, guidelines, and regulatory changes. This updated RP document is evidence rated. Each individual reference is evaluated for strength http://dx.doi.org/10.1016/j.aorn.2013.06.007
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RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE and quality, and each intervention is rated based on the level of the supporting evidence. Although the RP documents have previously been well referenced, the strength and quality of the evidence were not always apparent to the reader. To begin the evidence review process, a medical librarian conducts a systematic literature search to locate references related to the topic, including relevant regulations and professional guidelines. The lead author and a doctorally prepared evidence reviewer evaluate each reference and assign each one an appraisal score. Then the collective evidence that supports each intervention statement is reviewed, and a rating is assigned to the intervention. The RP document has been accepted for inclusion in the Agency for Healthcare Research and Quality National Guideline Clearinghouse, a searchable database of clinical practice evidence-based guidelines and abstracts. WHAT’S NEW Based on the literature review and appraisal, the RP document was updated to reflect new evidence. Topics included in the previous iteration of the RP document have been expanded to address additional aspects of safety for patients and health care personnel. For example, Recommendation I, related to occupational injuries for health care providers, has been expanded to include examples of specific riskreduction strategies for injury prevention. Recommendation II, which addresses fire safety, now includes the practice recommendation to conduct a fire risk assessment before every surgical procedure.
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Recommendation III on the safe use of electrical equipment includes the intervention of completing regular inspections of equipment before use. In Recommendation IV, the discussion of alert alarms has been expanded and an intervention added regarding the need to communicate any change to the alarm default parameters. Recommendation V recommends precautions to take in the event of a malfunction in a blanket- or solutionwarming cabinet. The subject of latex safety has been added to the RP document in Recommendation VIII. Care of the patient with a latex allergy or sensitivity was previously addressed in the “AORN latex guideline.”2 Recommendation IX includes the requirement of conducting an annual chemical risk assessment. Other significant changes to the content of the document include deleting topics that are addressed in other RP documents. Topics previously included in the “Recommended practices for a safe environment of care” that are addressed in other RP
Educational Resources n
n n n
n n n n
AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 553-572. AORN Video Library: Electrosurgery: Function, Practice & Safety [DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all. AORN Video Library: Fire Prevention in the Perioperative Suite [DVD]. http://cine-med.com/index.php?nav¼aorn&cat¼all. AORN Video Library: Latex in the Perioperative Setting: Strategies for the Patient and Staff Safety [DVD]. http://cine-med.com/ index.php?nav¼aorn&cat¼all. Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/firesafety/. Periop 101 Module: Natural Latex Sensitivity/Allergy. AORN, Inc. http://www.aorn.org/PeriopModules/. Safe Patient Handling and Movement Tool Kit. AORN, Inc. http:// www.aorn.org/ToolKits. Workplace Safety Tool Kit. AORN, Inc. http://www.aorn.org/ ToolKits.
Web site access verified April 16, 2013.
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documents include exposure to surgical smoke3,4; exposure to chemotherapeutic agents5; incorrect tubing connections5; and requirements for heating, ventilation, and air conditioning.6 Exposure to bloodborne pathogens7 and radiation safety8 are also outside the scope of this RP document. RATIONALE Identifying safety issues is the first step in creating and maintaining a safe perioperative environment. The RP document not only identifies hazards present for health care personnel and patients but suggests risk-reduction strategies that can be put into place before a problem occurs. Emphasis is placed on assessing the environment for hazards and understanding how to correct and report safety issues. Perioperative nurses can use the RP document to help educate team members about the potential hazards in the environment and how to mitigate risk. A multidisciplinary team can use this RP document to guide development of a quality management plan and to create policies and procedures for safety in the perioperative area. DISCUSSION Because this RP addresses a broad range of safety topics, the topics discussed in this article are limited to musculoskeletal injury, fire safety, electrical equipment, alarms, blanket- and solutionwarming cabinets, latex safety, and chemicals. The full RP document should be consulted for more information on these topics and additional topics that are not included in this article. Recommendation I Perioperative team members should take precautions “to mitigate the risk of occupational injuries that may result in death, days lost from work, work restrictions, medical treatment beyond first aid, and loss of consciousness.”1(p218) A significant hazard for all health care workers is the risk of musculoskeletal injury. Working in the perioperative environment may include performing tasks that are forceful or repetitive, that require maintaining 156 j AORN Journal
HUGHES awkward or static postures, or that involve physical exertion (eg, carrying heavy equipment).9 In addition, surgical and invasive procedure rooms have cords, booms, equipment on wheels, and the potential for wet floors, all of which can present the risk of slips, trips, and falls. Perioperative personnel should consider administrative, engineering, and behavioral controls when developing strategies for injury prevention. Administrative controls include educating personnel on ergonomic and safe patient handling techniques, which can decrease overall occupational injuries.10 Engineering controls include having appropriate patient handling equipment; use of transfer devices should be the norm in the organization. An example of a behavioral control is eliminating clutter by bundling and covering cables on the floor to reduce the risk of team members tripping over exposed wires and tubes.11 The physical environment should be conducive to safety. Adequate lighting, adequate storage, and ceiling-mounted electric or hydraulic booms, when feasible, can decrease the risk of injuries to personnel.11-13 The perioperative nurse should be aware of any potential hazards in the environment and know where and how to report any deficiencies. Recommendation II “Potential hazards associated with fire safety in the practice setting should be identified, and safe practices for communication, prevention, suppression, and evacuation should be established and followed.”1(p220) Each facility should have a written fire prevention plan that is developed by a multidisciplinary team. The plan should include team members’ responsibilities, an evacuation plan, and the frequency and content of fire safety education. AORN recommends performing a fire risk assessment before each surgical procedure (Figure 1). The RN circulator initiates the fire risk assessment, during which the team pinpoints fire risks and identifies ways to mitigate those risks. The elements of the risk assessment should be shared with the
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE Fire Risk Assessment Tool A fire risk assessment is performed by the surgical team. The surgical team will assess the patient for potential fire risks: open oxygen source, available ignition source, or surgical site above the nipple line. Circle appropriate option
Yes
No
Surgical site above the xiphoid process
1
0
Open oxygen source (patient receiving supplemental oxygen via any variety of face mask or nasal cannula)
1
0
Available ignition source (electrosurgical unit, laser or fiber-optic light source)
1
0
Total Score: 3 = High risk 2 = Low risk with the potential to convert to high risk 1 = Low risk RN circulator: Announce the risk assessment score to the other team members. Team: Follow the Fire Safety Plan according to unit-specific standards.
Figure 1. A fire risk assessment tool can be used before the start of each surgical procedure to determine whether the procedure includes a risk of fire. Printed with permission from Baltimore Washington Medical Center, Glen Burnie, MD.
entire surgical team. The communication includes identifying the use of ignition sources, potential oxidizers, and fuel sources. These three elements, which are necessary for a fire to occur, are known as the fire triangle (Figure 2). Perioperative nurses have influence over the fuel sources, which include clothing, drapes, and prep solutions. Perioperative nurses should help ensure that an ignition source does not come into contact with a fuel source.14 Examples include making sure a holster device is available to keep the electrosurgical active electrode (ie, pencil) from contacting the drapes when it is not in use and ensuring that prep solution is dry before the surgeon activates the electrosurgical device. The RN circulator and scrub person should make sure that sterile saline or water is available on the back table to douse flames if needed. Fire safety includes having clearly marked exits, hallways with good egress, and readily available fire extinguishers, as well as performing regularly
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scheduled fire drills. Participating in fire drills allows nurses and other team members to actively learn and practice what to do during a fire, where fire extinguishers are located, when to evacuate, and the best route for evacuation. A representative from the perioperative department should coordinate a drill with local fire departments after coordination with the facility’s fire safety officer. Fire drills should include a review of the exit path and how to use a fire extinguisher. The fire safety officer should conduct a post-fire drill review with the personnel who participated. The review should include a discussion about how to safely evacuate the area and protect patients. Recommendation III Perioperative team members should take precautions “to mitigate the risk of injury associated with the use of electrical equipment.”1(p224) If it is not handled and cared for correctly, electrical equipment presents a potential risk of fire or injury to patients and health care personnel.15 For example, a frayed cord or a cord separating from the plug could convey an electrical shock or start a fire. Personnel at every facility should have a mechanism in place for regularly inspecting new and existing equipment for damage periodically and before use. Perioperative nurses may be asked to participate in the inspection or to gather necessary equipment. Each facility should identify how equipment is inspected and how personnel are made aware that the inspection has been completed (eg, an updated sticker). Personnel should also assess the facility’s ability to provide the necessary power source to the equipment. For example, some equipment (eg, robotics, lasers) requires specific electrical load capabilities. Although the previous edition of this RP document recommended that use of extension cords be avoided, the new document allows for the use of electrical extension cords when appropriate. The grade of wire and type of plug should match the equipment and the facility power source. Mismatched electrical characteristics can cause AORN Journal j 157
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HUGHES any changes in the alarm parameters or tone are included in the patient hand-off communication between health care providers.19 In each organization, clinical engineering or biomedical department personnel should develop procedures for regular testing of clinical and alert alarms,17,18 and perioperative nurses should understand how the facility reviews and tests alarms. The testing may be performed at the beginning of the day or on a set schedule. Perioperative nurses also should collaborate with clinical engineering personnel to help maintain an inventory of devices with clinical alarms and track the testing of devices.
Figure 2. The AORN Fire Triangle illustrates the three elements necessary for a fire and the members of the perioperative team who frequently influence the elements. Reprinted from Perioperative Standards and Recommended Practices with permission from AORN, Inc, Denver, CO. Copyright ª 2013. All rights reserved.
damage to the equipment and overheating of the cord.15 Recommendation IV Alarms in the perioperative setting are intended to alert personnel to changes in a patient’s clinical status or to equipment malfunctions. Perioperative team members should take precautions “to mitigate hazards associated with non-functioning clinical and alert alarms or with personnel failing to hear or failing to act on alarms.”1(p225) Perioperative nurses use clinical alarm systems as an adjunct to patient care; however, The Joint Commission has identified clinical alarms as a source of potential harm for the patient if they are not checked and used appropriately.16 Clinical alarms should be set so that all personnel can hear the audible alarm over competing noise.17,18 If default parameters are changed on a clinical alarm, there must be clear verbal and visual communication among personnel about what changes were made. Perioperative RNs should help ensure that 158 j AORN Journal
Recommendation V A warm blanket may help comfort a patient and mitigate anxiety during the surgical event; however, perioperative team members should take precautions “to avoid thermal injuries related to warming solutions, blankets, and patient linens in blanket- and solution-warming cabinets.”1(p225) Thermal injuries are a potential safety hazard in the perioperative setting because patients are sedated and may not be able to communicate any discomfort from overheated linens or solutions. Warming cabinets should be labeled to identify the items that may be placed in the cabinet. An example is to label the outside of each cabinet shelf to indicate the permitted contents (eg, blankets on top, fluid on bottom).20 The temperature of each unit should be set, monitored, maintained, and documented according to organizational policy and manufacturers’ specifications. A manual log may be used if the temperature is not recorded via an electronic recording system. The temperature reading should be visible to the person retrieving the item from the warmer so he or she can verify that the item is warmed to a safe temperature. Any warmed item that is not the correct temperature when removed from the warmer (ie, is too warm or too cold) may indicate that the equipment is malfunctioning, and this should be reported to clinical engineering or biomedical department personnel.21
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE Fluid-warming cabinets should be labeled “for fluid only.” Fluid manufacturers have recommendations for temperature settings and for the length of time that fluids may be warmed safely. Perioperative nurses should label any solutions placed in a warming cabinet with the date that the solution was placed in and removed from the cabinet to help determine when the solution has reached its maximum shelf life and ensure it has not been in the warming cabinet for longer than the solution manufacturer’s recommended warming time.20 “The temperature of solutions on the sterile field should be remeasured before administration.”1(p226) Solutions intended for IV administration should be warmed only with technology specifically designed to warm these solutions because these may overheat if placed in a warming cabinet.20,22 Recommendation VIII The “AORN latex guideline”2 has been retired, and the recommendations related to latex safety have been updated and included in the current edition of the “Recommended practices for a safe environment of care.” The recommendation states, “A protocol to establish a natural rubber latexesafe environment should be developed and implemented.”1(p229) An allergic reaction to latex could cause a patient to experience anaphylaxis during a surgical procedure.23-25 In addition, health care personnel are frequently exposed to latex in the surgical environment and thus are at risk for developing latex sensitivity.26 Latex exposure may occur through contact with products containing latex or through airborne particles. Perioperative personnel should wear low-protein or powder-free latex gloves or latex-free gloves to minimize their own latex exposure.27 AORN’s latex recommendations include conducting a thorough preoperative assessment of each patient. In the assessment, the perioperative RN should address at least the patient’s history of longterm bladder care, history of multiple surgical procedures, food allergies (eg, banana, kiwi,
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avocado, chestnut, raw potato), and occupational exposure to latex. Patients with latex sensitivity or allergy should be identified with a bracelet or wristband, on the medical record, and on the patient’s bed. The patient should be scheduled as the first patient of the day, because potentially fewer latex proteins will be airborne in the OR if no other procedures have been performed in the OR that day.28 The perioperative RN can help provide the latexsensitive or -allergic patient with a latex-safe environment by gathering non-latex products, removing products that contain latex from the room, and posting signs on the doors of the OR to alert personnel that the patient has a latex sensitivity or allergy. The nurse should include a patient’s latex sensitivity or allergy in hand-off communication to other health care personnel.24 When withdrawing medication from a vial, the perioperative nurse should not remove the stopper of the vial. In a review of the literature, no evidence was found to support the practice of removing medication vial stoppers to prevent contact with latex in the stopper; the medications may already contain latex from contact with the stopper during transport and storage.25 The stopper should be punctured only once to decrease the possibility of introducing latex proteins into the medication.25 A multidisciplinary team approach should be taken in caring for patients with latex sensitivity or allergy. A member of the materials management team should review current and potential purchases of products containing latex with the clinical staff. After the products are identified, clinical personnel on the value analysis team may be able to assist with appropriate purchase selections for latex-safe products. Recommendation IX Improper handling of chemicals can result in injury to health care personnel and patients (eg, burns, eye damage, respiratory problems). As required by the Occupational Safety and Health Administration,29 health care personnel must take precautions “to AORN Journal j 159
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mitigate the risks associated with the use of chemicals in the perioperative setting (eg, methyl methacrylate, glutaraldehyde, formalin, ethylene oxide).”1(p231) The RP document provides guidance on the use of each of these chemicals. Health care organizations must follow the most stringent of the federal, state, or local regulations for chemical handling and disposal. Safety data sheets, formerly called material safety data sheets, must be readily accessible to employees within the practice setting.29 The health care organization must annually perform a chemical hazard risk assessment within the unit or facility that includes requirements for handling, storing, and disposing of chemicals and for managing spills and treating chemical exposures.29 Each perioperative health care provider has a responsibility to know how and where to seek information regarding chemicals in his or her practice setting. A hazardous chemical spill drill could be performed in addition to annual fire safety drills. The Final Four The final four recommendations in each AORN RP document discuss education/competency, documentation, policies and procedures, and quality assurance/performance improvement, as applicable. These four topics are integral to the implementation of AORN practice recommendations. Personnel should receive initial and ongoing education and competency validation as applicable to their roles. Implementing new and updated recommended practices affords an excellent opportunity to create or update competency materials and validation tools. AORN’s perioperative competencies team has developed the AORN Perioperative Job Descriptions and Competency Evaluation Tools30 to assist perioperative personnel in developing competency evaluation tools and position descriptions. Documentation of nursing care should include patient assessment, plan of care, nursing diagnosis, and identification of desired outcomes and interventions, as well as an evaluation of the patient’s 160 j AORN Journal
HUGHES response to care. Implementing new or updated recommended practices may warrant a review or revision of the relevant documentation being used in the facility. Policies and procedures should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting. New or updated recommended practices may present an opportunity for collaborative efforts among nurses and personnel from other departments within the facility to develop organization-wide policies and procedures that support the recommended practices. The AORN Policy and Procedure Templates, 3rd edition,31 provides a collection of 30 sample policies and customizable templates based on AORN’s Perioperative Standards and Recommended Practices.32 Quality assessment and improvement activities assist in evaluating the quality of patient care, the presence of environmental safety hazards, and the formulation of plans for taking corrective actions. For details on the final four practice recommendations that are specific to the RP document discussed in this article, please refer to the full text of the RP document. AMBULATORY PATIENT SCENARIO A busy, six-room outpatient surgical facility located in the Midwest routinely prepares its patients with a preoperative telephone call. The preoperative nurse asks the patient about health history, including a family history of malignant hyperthermia, and about medication and food allergies. The patient receives education related to the surgical procedure and surgeon preferences. Ms D is a 35-year-old woman scheduled for a laparoscopic umbilical hernia repair. The patient is herself a perioperative RN, and during her preoperative assessment, she tells the preoperative nurse that she has sensitivity to latex. The preoperative nurse immediately reports the patient’s latex sensitivity to the perioperative team. The RN circulator and the scrub person prepare the OR according to the surgeon’s preferences and with consideration for the patient’s latex sensitivity. They
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE post signs stating “Latex Allergy” on the OR doors to alert anyone entering the room. They examine each item carefully to determine whether it contains any latex and remove those that do from the OR, substituting latex-free alternatives. They complete the counts, and the RN circulator goes to meet Ms D. The nurse confirms the intended procedure with Ms D, and they discuss her latex sensitivity. The RN circulator explains that non-latex gloves will be used and that all of the products in the room have been inspected to make sure they do not contain latex. A nursing diagnosis includes the potential for hypothermia and retained foreign object and the need to implement latex allergy precautions. A forced-air warming device is placed on the patient before the induction of anesthesia. The counts are correct throughout the procedure. No signs and symptoms of latex allergy are noted during the procedure. The patient’s surgery is completed without complication. The RN circulator includes the information about the patient’s latex sensitivity in the hand-off report to the postanesthesia care unit nurse. The patient recovers as expected and meets all criteria for discharge to home. HOSPITAL PATIENT SCENARIO The environmental safety manager, OR manager, chief of anesthesia, and perioperative educator in an urban, mid-Atlantic community hospital plan to conduct an unannounced fire drill. The hospital safety officer notifies the local fire department and the insurance carrier with the date and time of the event. The time is scheduled as an inservice education program for personnel from the surgical and anesthesia departments; however, the
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participants are unaware that the subject of the education program will be a fire drill. On the day of the drill, perioperative personnel are separated into three rooms, and each room has an assigned leader who distributes scripts for the drill. The leader assigns each person a role (ie, RN circulator, scrub person, surgeon, anesthesia professional, nursing assistant, student) before the scenario starts. In room one, the group scenario describes a patient undergoing a tracheostomy on a patient care bed when the bed begins to emit smoke from the motor area. The leader watches how group members respond to the situation. Several team members leave the room in search of fire extinguishers and to alert the charge nurse. The leader determines that too much time lapses and declares that everyone in the room died from smoke inhalation. In room two, the group scenario describes a patient undergoing an upper body procedure when the electrosurgical device begins to shoot flames across the room. This group quickly pulls the fire box alarm and gathers up the patient to evacuate the room. They choose to leave by an old, unused loading dock exit because the exit is close
Resources for Implementation n n n
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AORN Syntegrity Framework. AORN, Inc. http://www.aorn.org/ syntegrity. ORNurseLinkTM. http://ornurselink.aorn.org. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/ JobDescriptions. Policy & Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. Ambulatory Surgery Center Resources [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/ Ambulatory_Surgery_Center_Resources.aspx
Editor’s notes: AORN Syntegrity is a registered trademark and ORNurseLink is a trademark of AORN, Inc, Denver, CO. Web site access verified April 16, 2013.
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to the main OR doors. The group members discover that they cannot bring the patient, who is on the OR bed, down the blocked ramp. The scenario ends at this point because the team is not successful in evacuating the patient. In room three, the group scenario describes a fire that develops during a surgical procedure because the electrosurgical active electrode (ie, pencil) lying on the drape is accidentally activated and ignites the drapes that are covering the patient. The group members are able to smother the flames with normal saline from the back table. They elect not to evacuate the patient because the fire has been extinguished. The drapes are removed from the patient and the patient is assessed for injury. It is determined that the patient has not been injured. The patient is re-draped and the sterile field re-established. The procedure is resumed. After all three scenarios conclude, the safety officer conducts a post-drill briefing with all involved personnel. They evaluate each scenario and highlight the weak points. In the first scenario, the patient should have been transferred quickly from the bed to a stretcher or to another OR bed. The smoking bed should have been isolated and the fire extinguished. The second group relates that they tried to evacuate, but the exit ramp was blocked, which taught the group that the loading dock exit is only safe for personnel and patients who can walk. The third group reacted the fastest to their scenario. Lessons learned from that scenario were that fire can erupt very quickly and the response must be fast to prevent harm. CONCLUSION The AORN “Recommended practices for a safe environment of care”1 encompasses a wide range of topics, and the importance of a safe environment of care is clearly outlined. Each topic in the document can have a significant effect on patient and personnel safety. Key takeaways include the following: n
Musculoskeletal injuries often can be prevented with the use of transfer devices and other measures.
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Fire safety involves the entire health care team; vigilance with each patient interaction will lead to a reduced risk of surgical fires. Health care team members should use electrical devices and components safely and correctly to avoid potential harm. Clinical alarms and alert alarms can notify personnel of a patient’s changing condition or an equipment malfunction as long as they can be heard above competing noise. Perioperative team members should know how to monitor and maintain correct temperatures in warming devices. Screening patients for latex sensitivity or allergy before surgery and using latex-safe products increases the safety of the environment. Improper handling of chemicals can result in injury to health care workers and patients. Safety data sheets must be readily accessible to health care workers for every potentially hazardous chemical in the practice setting.
The “Recommended practices for a safe environment of care” outlines how perioperative personnel should practice within the recommendations. Perioperative nurses should review the RP document with their colleagues and managers to help develop clear and comprehensive policies and procedures for their facilities. Health care workers and patients expect and deserve a safe environment.
References 1. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:217-241. 2. AORN latex guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 605-620. 3. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:125-141. 4. Recommended practices for laser safety in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:143-156. 5. Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-293.
RP IMPLEMENTATION GUIDE: A SAFE ENVIRONMENT OF CARE 6. Recommended practices for a safe environment of care: part II. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc. In press. 7. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 8. Recommended practices for reducing radiological exposure in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:295-304. 9. Esser AC, Koshy JG, Randle HW. Ergonomics in officebased surgery: a survey-guided observational study. Dermatol Surg. 2007;33(11):1304-1313. 10. Reddy PP, Reddy TP, Riog-Francoli J, et al. The impact of the Alexander technique on improving posture and surgical ergonomics during minimally invasive surgery: pilot study. J Urol. 2011;186(4 suppl):1658-1662. 11. Cappell MS. Accidental occupational injuries to endoscopy personnel in a high-volume endoscopy suite during the last decade: mechanisms, workplace hazards, and proposed remediation. Dig Dis Sci. 2011;56(2): 479-487. 12. van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc. 2009;23(6):1279-1285. 13. AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:553-572. 14. Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol. 2008;21(6):790-795. 15. NFPA 99: Health Care Facilities Code Handbook. Quincy, MA: National Fire Protection Association; 2012. 16. Medical device alarm safety in hospitals. Sentinel Event Alert. April 8, 2013;50. http://www.jointcommission .org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF. Accessed June 13, 2013. 17. Clinical Alarms Task Force. Impact of clinical alarms on patient safety: a report from the American College of Clinical Engineering Healthcare Technology Foundation. J Clin Eng. 2007;32(1):22-33. 18. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 19. Brown JC, Anglin-Regal P. Clinical alarm management: a team effort. Biomed Instrum Technol. 2008;42(2): 142-144.
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20. Warming cabinets. Oper Room Risk Manag. 2010; 2(Surgery 7). https://www.ecri.org/Documents/RM/ ORRM_TOC/SU7ES.pdf. Accessed June 19, 2013. 21. Huang S, Gateley D, Moss AL. Accidental burn injury during knee arthroscopy. Arthroscopy. 2007;23(12):1363. e1-1363.e3. 22. Limiting temperature settings on blanket and solution warming cabinets can prevent patient burns. Health Devices. 2005;34(5):168-171. 23. Pollart SM, Warniment C, Mori T. Latex allergy. Am Fam Physician. 2009;80(12):1413-1418. 24. Mertes PM, Lambert M, Gueant-Rodriguez RM, et al. Perioperative anaphylaxis. Immunol Allergy Clin North Am. 2009;29(3):429-451. 25. Heitz JW, Bader SO. An evidence-based approach to medication preparation for the surgical patient at risk for latex allergy: is it time to stop being stopper poppers? J Clin Anesth. 2010;22(6):477-483. 26. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010; 126(3):477-480. 27. Power S, Gallagher J, Meaney S. Quality of life in health care workers with latex allergy. Occup Med (Lond). 2010;60(1):62-65. 28. Bernardini R, Catania P, Caffarelli C, et al. Perioperative latex allergy. Int J Immunopathol Pharmacol. 2011;24(3 suppl):S55-S60. 29. Occupational Safety and Health Standards. Toxic and hazardous substances: hazard communication. 29 CFR x1910.1200. Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show _document?p_table¼STANDARDS&p_id¼10099. Accessed April 9, 2013. 30. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. 31. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. 32. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013.
Antonia B. Hughes, MA, BSN, RN, CNOR, is a perioperative education specialist, Baltimore Washington Medical Center, Edgewater, MD. Ms Hughes has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for a Safe Environment of Care
2.2 www.aorn.org/CE
PURPOSE/GOAL To enable the learner to take an active role in implementing recommended practices for a safe environment of care in his or her perioperative practice setting.
OBJECTIVES 1. 2. 3. 4. 5. 6. 7.
Explain strategies for safe patient handling. Discuss elements of fire safety. Describe precautions for safe use of electrical equipment. Discuss appropriate use of clinical and alert alarms. Describe precautions to avoid thermal injuries. Explain actions to take for the patient with latex sensitivity. Describe the components of a chemical hazard risk assessment.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS 1.
Educating perioperative personnel on ergonomic and safe patient handling techniques to prevent injuries is an example of a. b. c. d.
2.
sharing the elements of the risk assessment with the entire surgical team. 4. identifying the use of ignition sources, potential oxidizers, and fuel sources. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 3.
an administrative control. a behavioral control. an engineering control. a work practice control.
3.
The element of the fire triangle that perioperative nurses most commonly have influence over is a. the fuel source. b. the ignition source. c. the oxidizer.
4.
The elements of a fire drill should include 1. the location of fire extinguishers.
A fire risk assessment performed before each surgical procedure includes 1. 2.
pinpointing fire risks. identifying ways to mitigate fire risks.
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CE EXAMINATION 2. 3. 4.
how to use a fire extinguisher. the best route for evacuation. a post-fire drill review. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
5.
Electrical extension cords may be used in the OR when appropriate as long as the grade of wire and type of plug match the equipment and the facility power source. a. true b. false
6.
Changes to the default parameters of a clinical alarm should be communicated 1. during the patient hand off. 2. to The Joint Commission. 3. verbally. 4. visually. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
7.
Perioperative nurses should label any solutions placed in a warming cabinet with the date that the solution was 1. placed in the cabinet. 2. purchased. 3. removed from the cabinet. 4. manufactured.
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a. 2 and 4 c. 1, 2, and 3
b. 1 and 3 d. 1, 2, 3, and 4
8.
Topics related to latex sensitivity that the perioperative RN should address during the preoperative assessment include 1. food allergies. 2. a history of multiple surgical procedures. 3. occupational exposures. 4. risk factors for malignant hyperthermia. a. 1 and 4 b. 2 and 3 c. 1, 2, and 3 d. 1, 2, 3, and 4
9.
Perioperative personnel should remove the stopper from medication vials before withdrawing medication to reduce the potential for contaminating the medication with latex proteins. a. true b. false
10.
The chemical hazard risk assessments should include requirements for 1. handling chemicals. 2. managing chemical spills. 3. storing chemicals. 4. treating chemical exposures. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for a Safe Environment of Care
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Explain strategies for safe patient handling. Low 1. 2. 3. 4. 5. High 2. Discuss elements of fire safety. Low 1. 2. 3. 4. 5. High 3. Describe precautions for safe use of electrical equipment. Low 1. 2. 3. 4. 5. High 4. Discuss appropriate use of clinical and alert alarms. Low 1. 2. 3. 4. 5. High 5. Describe precautions to avoid thermal injuries. Low 1. 2. 3. 4. 5. High 6. Explain actions to take for the patient with latex sensitivity. Low 1. 2. 3. 4. 5. High 7. Describe the components of a chemical hazard risk assessment. Low 1. 2. 3. 4. 5. High
8. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 9. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 10.Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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11. Will you change your practice as a result of reading this article? (If yes, answer question #11A. If no, answer question #11B.) 11A. How will you change your practice? (Select all that apply) 1. 2. 3.
4.
5.
I will provide education to my team regarding why change is needed. I will work with management to change/ implement a policy and procedure. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. Other: ________________________________
11B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. 2.
CONTENT
2.2
3. 4.
The content of the article is not relevant to my practice. I do not have enough time to teach others about the purpose of the needed change. I do not have management support to make a change. Other: ________________________________
12. Our accrediting body requires that we verify the time you needed to complete the 2.2 continuing education contact hour (132-minute) program: _________________________________
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