or connection magazine - volume 3; issue 2

5

TheAligning practice with policy to improve patient care

Volume 3, Issue 2

Back to Basics:Electrosurgery

How to Thrive ina Tough Economy

FREE CE PAGE 22

PressureUlcer

Factorsto Keepin Mind

Surgical Site Infections:Are you playing yourpart in prevention?

About MedlineMedline, headquartered in Mundelein, IL, manufactures and distributesmore than 100,000 products to hospitals, extended care facilities,surgery centers, home care dealers and agencies and other markets.Medline has more than 700 dedicated sales representatives nationwideto support its broad product line and cost management services.

© 2008 Medline Industries, Inc. The OR Connection is published by MedlineIndustries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Meeting the highest level of national and international quality standards,Medline is FDA QSR compliant and ISO 13485 registered. Medlineserves on major industry quality committees to develop guidelinesand standards for medical product use including the FDA MidwestSteering Committee, AAMI Sterilization and Packaging Committeeand various ASTM committees. For more information on Medline,visit our Web site, www.medline.com.

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Aligning practice with policy to improve patient care 3

PATIENT SAFETY

16 Back to Basics: Electrocautery Safety and OR Fire Prevention24 Left Behind30 World Health Organization Issues Safety Checklist for

Surgical Teams37 Surgical Site Infections43 Flipping the Switch on Pressure46 Five Pressure Ulcer Factors to Keep in Mind

OR ISSUES

40 Great Ideas from Your Peers: Surgical Skin Prep Solutions50 The History of the Surgical Technologist

SPECIAL FEATURES

5 Letters from Our Readers13 SCIP’s Role in the CMS 9th Scope of Work Proposal32 Moments of Truth54 A Place of Healing?58 Callie Craig: A Nurse Hero62 How to Thrive in a Tough Economy68 Angel’s Passion for Pink71 Medline Supports Breast Cancer Awareness73 Recipe: Guacamole

CARING FOR YOURSELF

61 Building Unshakable Self-Confidence72 Ease the Discomfort of PMS

FORMS & TOOLS

76 Electrosurgery Checklist78 Electrosurgical Cautery Safety81 Pressure Ulcer Prevention86 Surgical Safety Checklist89 Checklist: Organizational Assessment Questions Regarding

Management Commitment to Employee Involvement90 Confidential Incident Report

EditorSue MacInnes, RD, LDClinical EditorAlecia Cooper, RN, BS, MBA, CNORContributing EditorAndy J. Mills, MBA, MWMArt DirectorMike GottiCopy EditorLaura KuhnClinical TeamJayne Barkman, RN, BSN, CNORRhonda J. Frick, RN, CNORAnita Gill, RNMegan Giovinco, RN, CNOR, RNFAKimberly Haines, RN, Certified OR NurseJeanne Jones, RNFA, LNCCarla Nitz, RN, BSNConnie Sackett, RN, Nurse ConsultantClaudia Sanders, RN, CFAAngel Trichak, RN, BSN, CNORPerioperative Advisory BoardGail Avigne, RNShands Teaching Hospital (UFL), FloridaCaroline Copeland, RN MPHSouthern Hills Hospital & Medical CenterCathy Crandall, RNHealthTrust Purchasing Organization, TennesseeLarry Creech, RN, MBA, CDTCarilion Health System, VirginiaPat DʼErrico, RN, CNORMedical Center of Central Georgia, GeorgiaBarbara Fahey, RN CNORCleveland Clinic, OhioZaida Jacoby, RN, MA, M.EdNYU Medical Center, New YorkSherron Kurtz, RN, MSA, MSN, CNOR, CNAAWellstar Kennestone Hospital, GeorgiaWayne Malone, RNPhysicians Hospital, TexasLynda Mansfield, RN, CNOROrange County Memorial, CaliforniaJackie Minor, RN CNORHuntsville Hospital, AlabamaJennifer Misajet, BSN, MHA, CNORExempla St. Joseph Hospital, ColoradoPricilla Ranseur, RN, MSN, CNORDuke University Hospital, North CarolinaMargie Voyles, RN, MS, CNORLakeland Regional Medical Center, FloridaMargery Woll, RN, MSN, CNORRush North Shore, Illinois

Page 13

Page 24

Page 62

2

OR ConnectionThe

Aligning practice with policy to improve patient care

Page 16

Dear Reader,Everyone agrees that preventing hospital-acquired conditions can save thousands of livesand millions of dollars. This is the time to takeaction. Hospitals across the country are implement-ing new strategies. All of us are feeling the swell ofchange and the push back that comes with it.Whether you are working with administration, mate-rials management, your staff, physicians, vendors,consultants or your peers, the journey isnʼt and wonʼtbe easy. Iʼve spoken to thousands of clinicians aboutthe barriers they are facing when it comes to imple-menting new policies and improving safety, qualityand patient satisfaction. Everyone wants to dowhatʼs right. The overwhelming things that we needto make that happen are teamwork, communication,education and – in many cases – additionalresources.

This edition of The OR Connection is about bringingpositive change into your facility. One key solutionthat can help your patients receive a higher standardof care is the use of a checklist. I know if somethingis not on my list, there is a chance it will be forgotten.With the day-to-day pressure, interruptions andstress that each of you must deal with in the OR, achecklist might be just the right calming factor.Checklists act as reminders to keep us on track, tomake sure weʼve covered everything we need to do.Youʼll want to take a look at Page 30, where you willfind the “Safety Checklist for Surgical Teams.” Thereare three recommended checklists:

1. Before anesthesia is induced2. Before skin incision3. Before the patient leaves the operating room

Then go to Page 86 in the Forms & Tools section,where you can tear out a copy of the checklists foryour own use.

But even with your checklist in hand, it might not beenough. That is why you should read through“Moments of Truth: How to enact a culture change atyour facility.” There are no miracles here, but a keenunderstanding and expert guidance on how to createa team that works together, problem-solves together,helps each other out to give the patient the bestcare possible.

Each of us contributes to the culture we work in, soI was thrilled with Wolfe Rinkeʼs article “How toThrive in A Tough Economy” (Page 62). This articletakes a closer look at how you can positively affectyour organization and your career in these times.

Last, but certainly not least, this edition is chock-fullof safety updates and information. Thank you forbeing a part of the team. We look forward to visitingwith you again in our next edition.

Sincerely,

Sue MacInnes, RD, LDEditor

“

4 The OR Connection

Content KeyWe've coded the articles and information in this magazine to indicate which patientcare initiatives they pertain to. Throughout the publication, when you see theseicons you'll know immediately that the subject matter on that page relates to oneor more of the following national initiatives:

• IHI's 5 Million Lives Campaign• Joint Commission 2007 National Patient Safety Goals• Surgical Care Improvement Project (SCIP)

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

THE OR CONNECTION I Letter from the Editor

This edition ofThe OR Connectionis about bringingpositive changeinto your facility.”


Letters from Our ReadersI really enjoy The OR Connection and find the articles to beinteresting, current and evidence-based. I look forward to thenew issues and have been able to implement some of thetools as teaching aids. Thank you very much for a publicationspecifically for the OR which puts policy and practice togetherto improve patient care and safety.

– Maureen Bollin, RN, CNOR, Perioperative Educator

As an educator, I was pleased with the timeliness of thearticles, the activities for the staff and their presentation. Thetopics are pertinent, and easy to read. I love the variety toarticles. I am only sorry I don't have all your issues. Thismagazine is a great resource tool, and when your staff needsan in-service, there is always something to draw on. Thankyou for publishing it, I hope it continues.

– K. Smith

This type of project is so very valuable to clinicians andestablishes your clinical credibility that is a major differentiator inthe market today. Kudos to you and to your clinical team.

– Sandy Wise, RN, MBA

I received this issue at AORN Congress this year inOrlando. What a GREAT magazine this is!!! It incorporatesso many of today's issues affecting perioperative care. Theeducation is invaluable. Thank you!

– Rose Trojkovich

I recently got to read Volume 2, Issue 1 given to me by afellow OR nurse and I really enjoyed the great reading andlove the format. I plan on using this info in education of the ORstaff in my facility. As an educator I am always looking for

fresh ideas and articles to share with my staff that is relevantand easy to understand. I just signed up for a subscription forour OR dept and want to thank you. I think the crosswordsand word search are fun and informative.

– Sara Smith, RN, CNOR

I wanted to pass along a thank you for The OR Connectionmagazine you dropped off. I really enjoy reading them. Thereis a lot of valuable information in it that I pass along to others.I get a lot of magazines in the mail and I must say this is oneof the few I review cover to cover and pass on to others.Medline does a nice job with this. Thanks again!

– Janna Petersen, RN

I love your magazine, keep up the good work!

– Lynne Arnaut

The Back to Basics series has become a hit at our twofacilities….I had been working hard on getting staff to readyour great issues of The OR Connection and now it lookslike it has finally happened.

– Sophia Schild

Great issue of The OR Connection! I am just amazed at thecontent, information, format, etc. You do have a gift for thispublication series.

– Nancy B. Bjerke, RN, MPH, CIC

Has The OR Connection been helpful at your facility? Isthere a topic youʼd love to see us tackle? Drop us a line [email protected]. Weʼd love to hear from you!

You Said It!

6 The OR Connection

Three Important National Initiativesfor Improving Patient Care

Achieving better outcomes starts with an understanding of currentpatient-care initiatives. Here’s what you need to know about national

projects and policies that are driving changes in care.

Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires

additional monitoring, treatment or hospitalization, or that results in deathGoal: To prevent five million incidents of medical harm over the next two years and to enroll more than

4,000 hospitals and their communities in the project.

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

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

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

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

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

Origin: Initiated in 2003 as a national partnership. Steering committee includes the followingorganizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and theJoint Commission

Purpose: To improve patient safety by reducing postoperative complicationsGoal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

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

5 Million Lives Campaign1

Joint Commission 2008 National Patient Safety Goals2

Surgical Care Improvement Project (SCIP)3


1. Prevent pressure ulcers2. Reduce methicillin-resistant staphylococcus

aureus (MRSA) infection3. Prevent harm from high-alert medications4. Reduce surgical complications5. Deliver evidence-based care for congestive heart failure6. Get boards on board7. Deploy rapid response teams8. Prevent adverse drug events (ADEs)

9. Deliver evidence–based care for acutemyocardial infarction

10.Prevent surgical-site infections11.Prevent central-line infections12.Prevent ventilator-associated pneumonia

By the numbers:• 3,954 hospitals currently enrolled• The Top 3 Interventions:

1. Adverse Drug Events (ADEs) – 3,0102. Surgical Site Infection (SSI) – 2,9233. Acute Myocardial Infarction (AMI) – 2,893

1. Surgical-site infections• Antibiotics, blood sugar control, hair removal, normothermia

2. Perioperative cardiac events• Use of perioperative beta-blockers

3. Venous thromboembolism• Use of appropriate prophylaxis

CMSʼs 9th Scope of Work is available at cms.hhs.gov/QualityIMprovement9thsow.asp#TopOfPage.SCIP measures are included in the 9th Scope of work. The 9th Scope of Work began August 1,2008 and runs for three years. To learn more, see the article on Page 13 of this issue.

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

Patient Safety

5 Million Lives Campaign: Twelve Interventions

Joint Commission 2008 National Patient Safety Goals

Surgical Care Improvement Project (SCIP): Target Areas

By the numbers:• 3,740 hospitals are submitting

data on SCIP measures, representing75 percent of all U.S. hospitals

• Currently, SCIP has more than 36association and business partners

UPDATE

UPDATE

• An IHI forum, “Celebrating 20 Years: The Futureof Health Care is Ours to Imagine,” will be held inNashville December 8-11, 2008

• For the latest on patient safety, visithttp://www.ihi.org/IHI/Topics/PatientSafety/ To learn more, visit www.ihi.org

UPDATE

• Improve accuracy of patient identification• Improve effectiveness of communication

among caregivers• Improve medication safety• Reduce risk of healthcare-associated infections

(Expanded in 2008 to include either WHOor CDC Hand Hygiene Guidelines)

• Reduce risk of patient harm from falls• Reduce risk of influenza and pneumoccocal

disease through immunization

• Reduce risk of surgical fires• Encourage patientʼs active involvement in their care• Prevent healthcare-associated pressure ulcers

(decubitus ulcers)• Identify safety risks inherent in patient population

(suicide, home fires)• Rapid response to changes in patient condition

(new for 2008)• Implementation of Universal Protocol for preventing

wrong-site, wrong-person, wrong-procedure surgery

To learn more about the proposed 2009 National Patient Safety Goals, go to www.jointcommission.org and see the News Flash on Page8 of this issue.

8 The OR Connection

Thanks again for your feedback – we look forwardto continuing to hear from you in the future!

News FlashCMS Proposes Additions to List of Hospital-Acquired Conditions for Fiscal Year 2009

On April 14, 2008, the Centers for Medicare & Medicaid Services(CMS) announced a proposed rule that would update paymentpolicies and rates under the hospital inpatient prospective paymentsystem (IPPS) for fiscal year (FY) 2009, beginning fordischarges on or after October 1, 2008. CMS is proposing toselect nine categories of hospital-acquired conditions (HACs)for FY 2009 in addition to the eight selected one year ago.

Candidate HACs for 2009• Surgical site infections following specific elective procedures:total knee replacement, laparoscopic gastric bypass andgastroenterostomy, ligation and stripping of varicose veins

• Staphylococcus aureus septicemia• Clostridium difficile-associated disease (CDAD)• Ventilator-associated pneumonia (VAP)• Deep vein thrombosis (DVT)/pulmonary embolism (PE)• Legionnairesʼ disease• Iatrogenic pneumothorax• Delirium• Extreme glycemic aberrancies

The announcement of the additional conditions that areselected will be made at the same time this magazine is goingto print. We encourage you to go to www.cms.gov to find outwhich of the 9 candidate HACs were chosen. Look foradditional information on the HACs selected for 2009 in thenext issue of The OR Connection magazine.

Joint Commission Announces2009 National Patient Safety Goals

The Joint Commission has announced the 2009 NationalPatient Safety Goals and related requirements for accreditedhospitals and critical access hospitals, accredited ambulatorycare facilities and offices in which surgery is performed.

In addition to the existing National Patient Safety Goals,the following modifications and additions have been made:

New:• “Eliminate transfusion errors related to patientmisidentification” was added to the “Improve accuracyof patient identification” goal

• Accurately and completely reconcile medications acrossthe continuum of care.

• “Implement best practices for preventing surgical siteinfections” was added to “Reduce the risk of health careassociated infections.”

The Results Are In!Hereʼs what you had to say about The OR Connection

The staff of The OR Connection would like to thank the 582 ofyou who took the time to complete our online readership survey!Weʼve learned a lot from what you had to say, and we wanted toshare some of the results with you!

We learned that Patient Safety is the most-read section of themagazine, followed closely by OR Issues. We were excited tolearn that 93 percent of you find the information in The ORConnection to be useful.

We also learned a lot about your priorities. Eighty-eight percent ofyou told us that patient safety is a priority, followed by turn-around time (73 percent), surgical site infection prevention (69 per-cent), education (35 percent) and new innovation (22 percent).


APIC Announces New Name for InfectionControl ProfessionalsTo articulate the expanding roles of its members, theAssociation for Professionals in Infection Control andEpidemiology (APIC) announced that infection controlprofessionals will now be referred to as “infectionpreventionists.” This newly created term joins the list ofprofessional titles such as hospitalists, intensivists andinterventionists introduced by the healthcare industry overthe past several years.

Infection preventionists direct interventions that protectpatients from healthcare-associated infections (HAIs) inclinical and other settings around the world. They work withclinicians and administrators to improve patient andsystems-level outcomes and reduce HAIs and relatedadverse events.

“The term infection preventionist clearly and effectivelycommunicates who our members are and what they do,”said Kathy Warye, APICʼs CEO. “Infection preventionistsdevelop and direct performance improvement initiatives thatsave lives and resources for healthcare facilities, so thiswas a natural transition – or a right-sizing of the name – tomore accurately reflect their role. By creating a new word,we hope to raise awareness about what infection preven-tionists uniquely contribute to patient safety, improved out-comes and bottom line savings to healthcare institutions.”

To view the complete press release, please visithttp://www.apic.org//AM/Template.cfm?Section=Home1.

Study: Time is of the Essence withPostoperative Indwelling Catheter Use

A recent study found that surgical patients whoseindwelling catheters were left in place for more than48 hours are twice as likely to develop a urinary tractinfection, resulting in increased length of stays, hospital-ization costs and rehospitalizations.

The study, published in the June 2008 issue of Archives ofSurgery, is titled “Indwelling Urinary Catheter Use in the Post-operative Period: Analysis of the National Surgical InfectionPrevention Project Data.” It was authored by Heidi Wald, MD,MSPH; Allen Ma, PhD; Dale Bratzler, DO, MPH and Andrew M.Kramer, MD.

Data used in the study was collected from nearly threethousand U.S. acute care hospitals participating in the SurgicalCare Improvement Project. The study revealed that of thesurgical patients who had received indwelling catheters, halfhad the catheters in place for more than two days. The groupwhose catheters were left in for more then 48 hours was twiceas likely to develop a urinary tract infection.

The study clearly demonstrates that urinary catheters in post-operative patients should be removed as soon as possible todecrease the likelihood of an adverse outcome.

To learn more about the study, please visit http://archsurg.ama-assn.org/cgi/content/short/143/6/551.

News Flash

The six conditions targeted by Prevention Above All

and their complementary Medline product and program

solutions are:

• Wrong site surgerySurgical Time Out Procedure Drape

• Hospital-acquired infectionsHand Hygiene Compliance Program

• Pressure ulcersPressure Ulcer Prevention Program

• Harm avoidance and patient satisfactionEducational Packaging

• Objects retained after surgeryRF Surgical Detection System™

• Catheter-associated urinary tract infectionsSilvertouch™ Catheter

To learn more about Prevention Above All,contact your Medline representative, call1-800-MEDLINE or visit us atwww.medline.com/special/paa.

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Now is the time.This is the opportunity.

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Preventing HACs is one of the most important issues in

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fessionals must eliminate HACs and improve patient

safety — or risk losing Medicare reimbursement dollars.

The good news is that almost all HACs are preventable,

and with Medline’s Prevention Above All, you will have

the knowledge and products to prevent six of the most

common HACs. The program’s multi-layered approach

provides you with targeted evidence-based interventions

that will not only save lives but also improve your

bottom line.

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

Special Invitational Forum

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Board certified wound specialist with extensive experi-

ence in wound, ostomy & incontinence care.

Heidi Wald, MD, MSPH

Assistant Professor of Medicine, University of Colorado

Kathy Warye

Chief Executive Officer of Association for Professionals in

Infection Control and Epidemiology (APIC)

For more conference information,visit www.medline.com/special/paa.

• Learn about Prevention Above All

• Speaker biographies

• Select conference presentations (available 8/20)

• Request information on specific interventions

Medline presents an executive Prevention Above All forum focusing onthe implications of the new CMS guidelines, targeted interventions andpractical solutions.

Keynote speaker:

John Nance, JD

A founding member of the

National Patient Safety Foun-

dation and one of the foremost

thought leaders on change in

America’s healthcare system

and a regular contributor to

ABC World News and GoodMorning America, John isalso the author of 18 books,

including his latest, Why Hospitals Should Fly: TheUltimate Flight Plan to Patient Safety and Quality Care.

Featured speakers:

Deborah Adler

Senior designer at the design firm Milton Glaser, Inc.

and the inspiration behind Target’s ClearRx system

Dr. Dale Bratzler, DO, MPH

Medical Director of the Hospital Interventions Quality Im-

provement Organization Support Center and the Hospi-

tal Quality of Care Measures Special Study

Larry Creech, RN, MBA, CDT

Vice President Perioperative Surgical Services, Clarian

Health Partners

Dea Kent, RN, MSN, NP-C, CWOCN

Practicing nurse for 20 years and the manager and pri-

mary provider at the Wound Healing Center at St.

Joseph Hospital in Kokomo, Indiana

Dr. Andrew Kramer

Professor of Medicine, Head of Division of Healthcare

Policy and Research, University of Colorado

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On August 1, the Centers for Medicare & Medicaid Serviceslaunched its next three-year cycle of healthcare quality improvementinitiatives for Medicare providers, known as the 9th Scope of Work(SoW). Under the direction of CMS, the Quality ImprovementOrganization (QIO) Program consists of a national network of 53QIOs responsible for each U.S. state, territory and the District ofColumbia. QIOs work with consumers and physicians, hospitalsand other caregivers to refine care delivery systems to make surepatients get the right care at the right time, particularly patientsfrom underserved populations. The Program also investigatesbeneficiary complaints about quality of care.

SCIP’s Role in the CMS 9th

Scope of Work ProposalBy Dale Bratzler, DO, MPHMedical director, Hospital Interventions QualityImprovement Organization Support Center and theHospital Quality of Care Measures Special Study

Special Feature


14 The OR Connection

Cardiac• SCIP Card 2: Surgery patients on a beta-blocker prior to arrival

that received a beta-blocker during the perioperative period

Venous thromboembolism• SCIP VTE 1: Surgery patients with recommended venous

thromboembolism prophylaxis ordered• SCIP VTE 2: Surgery patients who received appropriate

venous thromboembolism prophylaxis within 24 hours priorto surgery to 24 hours after surgery

Facilities participating in SCIP are collecting data and thendepositing the data in the CMS Clinical Data Warehouse(CDW), a national repository from which hospital-specificperformance rates are derived for public reporting onHospital Compare. Additional information is available at:www.cms.hhs.gov/QualityImprovementOrgs (click on “Statementof Work”) and at www.medqic.org/scip.

About the AuthorDale Bratzler, DO, MPH, has been involved in healthcare qualityimprovement on the local, state and national level since 1987.Dr. Bratzler currently serves as the Medical Director for theHospital Interventions Quality Improvement Organization SupportCenter and the Hospital Quality of Care Measures Special Study.

The Patient Safety theme is designed to address areas of patientharm by using established, evidence-based research that improveshealthcare processes and systems. Key areas of focus in thePatient Safety theme include:• Improve inpatient surgical safety and heart failure rates

(SCIP/HF)• Decrease the rate of pressure ulcers

(PrU-Nursing Homes and Hospitals)• Reduce the use of physical restraints (PR)• Improve drug safety• Reduce rates of healthcare associated

methicillin-resistant Staphylococcus aureus (MRSA)• Providing quality improvement technical assistance

to nursing homes in need

The focus of the Surgical Care Improvement Project (SCIP) hasbeen the recruitment of hospitals for participation in the programʼsprocess measurements. The measurements were defined andrecommended through evidenced-based practice to improveoutcomes of surgical patients.

The specific SCIP measures include:Infection• SCIP INF 1: Prophylactic antibiotic received within one hour

prior to surgical incision• SCIP INF 2: Prophylactic antibiotic selection for surgical patients• SCIP INF 3: Prophylactic antibiotics discontinued within 24

hours after surgery end time (48 hours for cardiac patients)• SCIP INF 4: Cardiac surgery patients with controlled 6 a.m.

postoperative serum glucose• SCIP INF 6: Surgery patients with appropriate hair removal

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It could happen at any time, to anyone and when youleast expect it. If and when it does, your patient, you and yourcoworkers could suffer serious injuries, depending upon theextent and type of error.

The safe and proper use, maintenance and disposal ofelectrocautery equipment in the operating room should neverbe overlooked or taken too lightly. If you do, you could befaced with one of the most terrifying experiences of yourprofessional career. Complications and patient injury due toimproper use of electrocautery devices include inadvertentand advertent thermal injury, burn, fire, cardiac arrhythmiasand interference with pacemakers. Although all are seriouscomplications, a surgical fire can be the most critical.1

Two devastating casesFollowing a successful gallbladder surgery at a metropolitanmedical center in Boston, a female patient experienced a flashfire ignited on her midsection. The patientʼs abdomen wascleansed following her surgical procedure with an alcohol-based cleansing solution. The surgeon then decided toremove a mole from the patientʼs abdominal area usingelectrocautery. Blue flames immediately shot up from hermidsection – “similar to a flambé,” the surgeon told statehealth investigators. The patient suffered painful first- andsecond-degree burns.2

According to the ECRI Institute, 44 percent of operating roomfires occur during head, face, neck or chest surgery, whenelectrical surgical tools are closest to the oxygen the patientis breathing.2

A 68-year-old man was scheduled for ambulatory surgery toremove a skin lesion on his right cheek. A moderate amountof bleeding was encountered during the punch biopsies andan electrocautery device was used to cauterize the skin edges– igniting the nasal cannula and surgical drapes surroundingthe face. The surgeon poured sterile water from the operativetables on the patient and the nasal cannula to extinguish thefire. The nasal cannula and drapes were removed from thepatient and thrown to the floor. The nasal cannula continuedto burn until anesthesia personnel turned the oxygen off. Oncethe fire was extinguished, new instruments and drapes wereobtained. The patient was re-draped and the procedure wascompleted. A thorough examination indicated first- andsecond-degree burns involving both cheeks, as well as theright nasal vestibule.3

The history of electrocauteryCauterization began as a means to stop heavy bleeding,especially during amputations. The procedure was simple: apiece of metal was heated over fire and applied to the wound.This would cause tissues and blood to heat rapidly to extremetemperatures, causing coagulation of the blood and thuscontrolling the bleeding. Next came medical instrumentscalled cauters, used to cauterize arteries.

Electrocauterization (also called electric surgery or electro-surgery) is the process of destroying tissue with electricity. Itis widely used in many surgical procedures. The procedure ismost frequently used to stop the bleeding of small vessels orfor cutting through soft tissue. The electrocautery generator(ESG), more commonly referred to as an electrosurgical unit

Electrocautery Safety andOR Fire Prevention

By Alecia Cooper, RN, BS, MBA, CNOR

Patient SafetyBack to Basics Eighth in a Series


(ESU) or simply as a generator, powers an electrosurgicalsystem with electricity at an appropriate voltage, frequencyand waveform for cutting or coagulation, as required.

FrequencyTo prevent electric shock, an alternating frequency that ishigher than power from standard wall outlets is used. NormalAC “house-current” runs at 50-60 Hz and is quite lethal, sinceat every alternation nerves and muscles get stimulated, causingviolent cramps at 50 to 60 times per second. However, nerveand muscle stimulation cease at 100,000 Hz, due to alterationsbeing too fast for the cells to pick up. Electrosurgery can beperformed safely at “radio” frequencies above 100 kHz.4

Cutting vs. coagulationDifferent cauterizing effects can be achieved by changing thevoltage of the current as well as the pattern of electric pulses.When lower voltage is used with a continuous alternating cur-rent (AC), heat is produced very fast and tissue is completelyvaporized at the tip of the probe. The effect is “cutting.” Whena higher voltage current is used in a pulsed manner, heat isproduced more slowly, tissue damage is more widespread andblood coagulates. In many electrosurgery instruments, this iscalled “coagulation” mode. This is used for ablation. Usually a“blend” setting is available as well.

Monopolar vs. bipolarBoth monopolar and bipolar electrocautery involve high-frequency alternating current and a pair of electrodes, onereferred to as “active” and the other “returning.” The differencelies in the placement of the electrodes.

MonopolarCurrent is passed from the active electrode, where cauterizationoccurs, and the patientʼs body serves as a ground. A groundingpad is placed on the patientʼs body, usually the thigh, and itserves as the returning electrode, which carries the currentback to the machine. The placement of the return electrode iscritical in preventing extensive burns.

BipolarThe active and receiving electrodes are both placed at the siteof cauterization. The probe is usually in the shape of forceps,with each tine forming one electrode, cauterizing only the tis-sue between the electrodes.

ProbesDifferent shapes of cautery probes are used for differentpurposes. A common monopolar probe is pen-shaped butending in a small slender scalpel-shaped spatula of about 5 to30 mm. This can be used a both a coagulator and an electricscalpel. The typical bipolar probe resembles a pair of tweezersthat grasp and cauterize a small piece of tissue. There arevariations of these probes that can be used in both open andminimally invasive surgical procedures.

The chance of fireElectrosurgery electrodes and devices are frequently ignitionsources for surgical fires. These types of fires are a potentiallydevastating yet preventable adverse event. Thankfully, firesin the operating room are not frequent. According to ECRI,only 50 to 100 surgical fires are reported each year – but thefires can result in serious consequences to patients, damageto equipment and interruptions to operations.5


According to one ECRI report, an electrosurgical pencilcaused a drape fire because it was not placed in a non-conductive holster.6 In this incident, a pencil fell off the sterilefield, was not removed and instead was left dangling. A surgicalteam member leaned against the pencil, causing it to activate,arc through the drapes to an instrument table and ignite thedrapes. The flame spread rapidly up the drapes, vertically fromthe point of ignition, about two feet off the floor, to the patient.By this time, the fire was burning with such intensity that allother flammable materials on and around the patient ignitedand quickly burned. This fire was fatal to the patient. Did youknow that that materials burn more quickly when vertical?

There are three conditions that must be in place for a fire tooccur: fuel, oxygen and heat. When brought together, thesecomponents complete the fire triangle. Preventing a fire in theOR can be achieved by controlling the elements that make upthe fire triangle.

Control ignition sourcesThe most common ignition sources in the OR are electrosur-gical and/or electrocautery equipment and lasers. ECRIreports that approximately 68 percent of surgical fires involveelectrosurgical equipment and 13 percent involve lasers. Wehave control over ignition sources.6

ECRI recommends that during electrosurgery6:• Remove unneeded foot switches to avoid

inadvertent activation.• Place the electrosurgical pencil in its holster when

not in active use and place the electrosurgical unit inthe standby mode.

• Allow the tip of the pencil to be activated only by theindividual wielding it and when it is under directobservation of the surgeon.

• Use only active electrode tips that are manufacturedwith insulating sleeves.

• Do not use electrosurgery to enter the trachea.• Do not use electrosurgery in close proximity to

combustible materials and oxygen-rich atmospheres.• Dispose of electrocautery pencils properly. For

example, break off the cauterizing wire and capthe pencil.

Control oxygen levelsWe can control oxygen-rich environments in the OR, which in-clude any atmosphere where there is greater than 21 percentoxygen. While oxygen will not burn or explode, it can causematerials that will not ignite or that burn slowly in ambient airto easily ignite and burn rapidly. The vapor density of pure oxygen(1.1) is slightly heavier than air. This means that pure oxygenmay collect in depressions or under drapes or clothing.

Nitrous oxide use can increase effective oxygen levels above21 percent. Like oxygen, nitrous oxide also has a vapordensity greater than 1.0. With a vapor density of 1.53, it willcollect in low-lying areas as well.6

ECRI data shows that 74 percent of the reported surgical firesoccurred when oxygen levels were elevated above 21percent. It's important to understand that oxygen may collectand its concentration become elevated. This can occur undersurgical drapes, in clothing, on the surface of the skin due tothe presence of vellus (short, fine, "peach fuzz" body hair) andaround masks, tubes or nasal cannula when patients are pro-vided oxygen or nitrous oxide from compressed gas cylindersor piped medical gas systems.6

To control oxygen concentration levelsECRI recommends6:• That the requirement for 100 percent oxygen for

open delivery to the face (for example, when usingnasal cannula) be questioned if a lower concentrationis consistent with the patient needs.

• Stopping supplemental oxygen at least one minutebefore using electrosurgery, electrocautery or lasersurgery on the head or neck.

• Titrating the delivery of oxygen to the patient basedon the patientʼs blood-oxygen saturation.

• Tenting drapes to allow gases to drain away fromthe operating table.

• Using a properly applied incise drape, if possible,to help isolate head and neck incisions fromoxygen-rich atmospheres.

• Considering use of active gas scavenging of spacebeneath the drapes during oxygen delivery. Whenscavenging under the drapes, exercise caution sothat the space beneath the drapes doesnʼt collapse.

• Avoiding the use of nitrous oxide duringbowel surgery.

During oropharyngeal surgery, ECRIalso recommends:• Suction be used as near as possible to any potential

breathing gas leaks to scavenge the gases from theoropharynx of an intubated patient.

Control combustible materialsCombustible materials – fuel that will burn – surround thepatient in the OR and include the operating table bedding,headrests, clothing, straps, towels, drapes, sponges, dressings,hair, intestinal gases, tracheal tubes, body tissue, broncho-scopes, breathing systems, petroleum jelly, adhesives, hoses

Continued on Page 21

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and equipment covering – and this list is not complete.Flammable and combustible liquids are also present in theOR, including skin prep solutions, tinctures, degreasers,suture pack solutions and liquid wound dressings.

Understanding what can burn and which liquids are flammableor combustible is the first step in managing the fuel load for apotential fire. Allow flammable liquid preps (e.g., preps that arealcohol-based or contain acetone) to fully dry before drapingand avoid pooling the liquids when they are applied. Be awarethat pooled liquids can be wicked up into sponges, drapes,etc. and may take longer to dry. ECRI recommends that facialhair (e.g., eyebrows, beards and mustaches) be coated witha water-soluble surgical lubricating jelly to inhibit combustion.6

Know and practice the fire planService-specific fire plans have been required for many years.A fire plan is strongly recommend for surgical service. It shouldbe reviewed annually and it is recommended that quarterly firedrills be conducted. Surgical staff members should participatein at least one fire drill (conducted in the OR) every year, andit is especially important to:• Talk about what each OR team member will do if presented

with a fire involving a patient.• Walk through the plan and look for areas where response

can be improved.• Know who will be responsible for moving the patient, where

the patient will be moved and who will be movingcritical equipment.

Not all burns are externalNot all fires and burns are external to the patient. Internal fireshave been reported in the literature involving patients under-going laparoscopic procedures in oxygen-rich atmospheres(oxygen was mistakenly used for insufflation instead ofcarbon dioxide). They have also been caused by the use oflasers and non-metallic endotracheal tubes that were ignitedwhile in the patient. The burning endotracheal tube created afire similar to that which might have occurred had a blowtorchscorched the lungs.

Stray electrosurgical burns can cause internal injuries thatmight be difficult to detect because they may not be visible tothe surgeon. Figures show that 67 percent of stray electro-surgical burns go unnoticed during surgery and that 25 per-cent of the patients who suffer internal injuries stemming fromthese burns during laparoscopic procedures die.7 Insulationfailure on the electrosurgical device that results in burns andcapacitive coupling is cited as being the primary cause ofburns during laparoscopic procedures. With use, the tip of theESU can become extremely hot and, if inadvertently touchedto targeted tissue, can cause burns. Capacitive coupling canoccur if there is microscopic insulation failure in the device.

The insulationfailure providesan alternate elec-trical current pathbetween theactive electrodeand the patientreturn electrode,resulting in theburn. To minimizecapacitive cou-pling, use anelectrosurgicalwaveform withthe lowest volt-age necessaryto achieve thedesired surgical

effect.5 Instruments that use active electrode monitoring tech-nology (AEM) are also effective in preventing capacitivecoupling.7 These devices are shielded and monitored so that100 percent of their power is delivered where intended.

Refer to the Forms & Tools section starting on Page 76 to findan Electrocautery Checklist and an Electrosurgical CauterySafety policy and procedure. For additional support materialsregarding fire prevention in perioperative services, refer toAORNʼs guidance statement “Fire Prevention in the Oper-ating Room.”

References1 Gamal M, Lamont C, Greene FL, eds. Review of Surgery Basic Science andClinical Topics for ABSITE. New York: Springer; 2006.2 Kowalczyk L. Fires during surgeries a bigger risk than thought. Available at:http://www.boston.com/news/local/articles/2007/11/07/fires_during_surgeries_a_bigger_risk_than_thought/. Accessed July 15, 2008.3 Joint Commission International Center for Patient Safety. Preventing SurgicalFires: Who needs to be Educated? Available at: www.jcipatientsafety.org/15196.Accessed July 15, 2008.4 Cauterization. Available at: en.wikipedia/wiki/Cauterization. Accessed July 12,2008.5 DeRosier JM, Surgical Fires and Patient Surgical Burns. NCPS Tips – August/September 2003. Available at: www.va.gov/NCPS/TIPS/Docs/TIPS_Aug_Sept_03.doc. Accessed July 14, 2008.6 Focus on surgical fire safety. ECRI Health Devices. 2003;32(1):4-40.7 Avoiding Electrosurgical Injury During Laparoscopy: An Emerging Patient SafetyIssue. [Videotape] Washington: Communicore; 1997.


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Electrocautery Safety andOR Fire Prevention

www.medlineuniversity.com1. Register (free) or log in2. Click Free Courses tab3. Locate the puzzle and click Learn More,

then Begin Course4. Certificates are available online after

puzzle completion

Back to Basics Crossword Puzzle


Across1 Electrical fires due to the improper use of electro-

cautery equipment are a potentially devastatingyet _____ adverse event.

4 Complications and patient injury due to improperuse of electrocautery devices include inadvertentand advertent thermal injury, burn, _____, cardiacarrhythmias and interference with pacemakers.

5 A common monopolar _____ is pen-shaped.6 Use only active electrode tips that are manufactured

with _____ sleeves.7 Electrocautery is most frequently used to stop the

bleeding of small vessels or for_____ through softtissue.

8 Cauterization began as a means to stop heavy_____, especially during amputations.

9 To prevent electric shock, an alternating frequencythat is _____ than power from standard wall outletsis used.

10 The placement of the return _____ is critical inpreventing extensive burns.

11 _____ fires have been reported involving patientsundergoing laparoscopic procedures in oxygen-richatmospheres.

13 Preventing a fire in the OR can be achieved bycontrolling the elements that make up thefire _____.

15 There are three conditions that must be in place fora fire to occur: _____, oxygen and heat.

17 In bipolar cauterization, the active and receivingelectrodes are both placed at the site of _____.

21 Remove unneeded foot switches to avoid_____ activation.

24 The typical bipolar probe resembles a pairof _____.

27 Place the electrosurgical pencil in its _____ whennot in active use and place the electrosurgical unitin the standby mode.

28 A fire _____ is strongly recommended forsurgical service.

29 When a higher _____ current is used in a pulsedmanner, tissue damage is more widespread andblood coagulates.

30 _____ what can burn and which liquids areflammable or combustible is the first step inmanaging the fuel load for a potential fire.

Down2 Do not use electrosurgery to enter the _____.3 Do not use electrosurgery in close proximity to

_____ materials and oxygen-rich atmospheres.12 Electrocauterization is the process of destroying

tissue with _____.14 Different _____ effects can be achieved by

changing the voltage of the current as well as thepattern of electric pulses.

16 Allow the tip of the pencil to be _____ only by theindividual wielding it and when it is under directobservation of the surgeon.

18 Electrosurgery can be performed safely at “radio”frequencies _____ 100 kHz.

19 With _____ cauterization, current is passed fromthe active electrode, where cauterization occurs,and the patientʼs body serves as a ground.

20 _____ of electrocautery pencils properly. Forexample, break off the cauterizing wire and capthe pencil.

22 It's important to understand that oxygen maycollect under drapes and in clothing and itsconcentration become _____.

23 _____ reports that approximately 68 percent ofsurgical fires involve electrosurgical equipment.

25 A grounding pad is placed on the patientʼs body,usually on the _____, and serves as the returningelectrode, carrying the current back to the machine.

26 A _____ setting is available with most electrocauterydevices which allows for cutting and coagulation.

To receive one hour of CE credit, enter your answersonline at www.medlineuniversity.com


The averagesettlement in

malpractice casesinvolving RFOsis $50,000.2


A 42-year-old woman presented with a five-month historyof abdominal pain, nausea and vomiting. Physical exami-nation revealed a palpable epigastric mass. Five monthsprior, the patient had undergone an abdominal hysterectomyfor uterine leiomyomata. The rest of her examination andhistory were unremarkable. An abdominal computed tomog-raphy (CT) scan was performed. Review of this and the Scoutimage from the CT revealed a “density consistent with alaparotomy sponge in the left lower quadrant of theabdomen.” The patient returned to surgery for an exploratorylaparotomy and a sponge from her first surgery was foundand removed.1

How serious is the problem?Gossypiboma, or retained foreign objects, are a dangerousand costly issue.2 Current studies have found that retention ofsponges, sharps or instruments can occur as frequently asone in every 100 cases or 1 in every 5000 cases. Accordingto the American College of Surgeons, any facility thatperforms 8,000 to 18000 major cases annually will have oneincidence of a retained item yearly.3 These statistics arebased on claims data, but it is highly probable that even morecases are settled outside the legal system every year. Inaddition, it is likely that many more circumstances where“near misses” – incorrect counts of sponges and instrumentsthat were identified and resolved intraoperatively via manualsearches and X-rays – have happened.4 The average settle-ment in malpractice cases involving RFOs is $50,000. Theseitems that are inadvertently left behind when the surgicalincision is closed can cause pain, sepsis, bowel perforation,

adhesions and death.2 If this was not enough to make surgicalfacilities reexamine their count policies, the fact that they willnot receive their full Medicaid and Medicare reimbursementsif they fail to take steps to prevent eight avoidable hospital-acquired conditions – including RFOs – will. In short, if apatient must return to surgery to remove a foreign object leftbehind during a previous procedure, the hospital will have tofoot the bill.5

Traditionally, the manual counting of sponges, sharps andinstruments has been a utilized standard of practice in the sur-gical setting. Although helpful, there is no published data dis-cussing the effectiveness of this practice.4 In fact, accordingto a study done by the New England Journal of Medicine, inalmost 90 percent of cases involving a retained foreign ob-ject, a count was performed per policy and all objects werereportedly accounted for.6 Certain assistive devices such ashanging bags to place sponges in, needle boxes on the sur-gical field and wall-mounted boards for count documentationhave helped, but items continue to be left behind.4

How does this happen?So why do items get left behind? The surgical team is madeup of dedicated and conscientious healthcare providers –including anesthesiologists, surgeons, nurses and surgicaltechnicians – who are committed to a common goal of safe,efficient and effective functionality. These professionalsconstantly execute challenging tasks under considerable timepressures, often in chaotic, constantly changing, stressfulsituations.4 Although these practitioners have been trained

Retained foreign bodies harmboth patients and finances

By Megan Giovinco, RN, CNOR, RNFA

Patient Safety

Left Behind


and have the experience to deal with such an environment,human error can occur – especially when so many distractionsare present.7 Other risk factors that contribute to a greaterchance of something being missed include emergency surgery,unplanned changes in the procedure, patients with a highbody mass index, multiple changes in the surgical team andmultiple operative sites.2

Well, what more can be done? As with many things, commu-nication is key. Good communication between the surgicalteam is necessary for the prevention of retained foreignobjects.8 Intraoperatively, distractions, interruptions, noiseand traffic should be as limited as possible. When staffchanges occur, complete and accurate transmission ofrelevant information must be shared. This informationshould also be documented according to facility policy. To-ward the end of the procedure, the final count of surgicalsponges, sharps and instruments should be performed andinclude a visual and audible confirmation by at least twoteam members. This information should then be relayed tothe surgeon prior to closure of the surgical site.4

Although following these guidelineswill augment accuracy and reduceerrors, the fast pace and ever-changing conditions of the ORenvironment do not always allowfor them to take place as well asthey would in an ideal setting.

It is for this reason that surgical facilities must provide theresources necessary to establish the safest OR environmentpossible.4 Counting policies should be re-evaluated,revised and updated as needed in order to adapt them to thespecific clinical settings of each particular facility and to keep

them up to date with AORN Standards and RecommendedPractices.9 These routine assessments of policy should alsoinclude investigating any new tools or procedures availablethat will increase patient safety and reduce retentionof counted items.6 Many institutions encourage obtaining aroutine X-ray of any case considered high risk for a RFO,such as traumas or morbidly obese patients.3 However, it hasbeen noted in a recent study that three out of 29 X-raysobtained for an incorrect count falsely reported that noforeign objects were seen on the films.9

Technological advancesNew technologies, such as radio frequency identification,have recently been gaining acceptance in many of thenationʼs ORs. Radio frequency ID-tagged sponges are elec-tronically tagged with a small microchip about 4 x 12 mm insize. This chip is small and sturdy enough that the spongesthat house it can be used the same way non-RFID spongesare. Detection is still possible even if the gauze is balled orfolded up. One can even clamp directly over this chip withoutimpairing its functionality.10 By passing a hand-held, battery-powered wand over the patient, one can detect whether ornot a sponge was left behind.9 These RFID chips are availablein sponges, gauze and towels in a variety of sizes. The wandcan also be used off the surgical field by the circulator to scanfor sponges that may have been inadvertently thrown intothe trash.10

This system is not meant to replace the traditional countingsystem, but to augment it. Since the majority of retainedsponges happen when the counts are thought to be correct,a clear scan and a reconciled surgical count give the scrubnurse and circulator the assurance and peace of mind thattheir findings are also correct.10 Clinical evaluations performedby surgeons and perioperative personnel have rated theRFID systems very highly for ease of use and the possibilityof decreasing the risk of incorrect counts.9


If a patient must returnto surgery to removea foreign object left

behind during a previousprocedure, the hospitalwill have to foot the bill.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.RF Detect® is a registered trademark of RF Surgical Systems, Inc.RF Surgical® is a registered trademark of RF Surgical Systems, Inc.RF Surgical Detection System™ is a trademark of RF Surgical Systems, Inc.

The RF Surgical® Detection System™

Perioperative nurses spend 15 to 30 stressful minutesmanually counting surgical sponges and instruments before,during and after each operation. Even with such protocols,studies suggest that given the 28.4 million inpatient opera-tions performed nationwide, more than 1,500 cases of aretained foreign body occur annually in the United States.1

According to Harvard University researchers, 88 percent ofretained sponge cases falsely recorded a “correct” manualcount of sponges at the end of the procedure, leadingstaffs to unknowingly leave behind sponges in patients.

Prevent Retained Surgical ObjectsRF Detect® is the first easy-to-use scanning system toaccurately detect and prevent retained sponges, gauzeand towels in patients.

No larger than a grain of rice, RF Detect brings majorimprovements in patient safety to the OR.

Are You Covered?As of October 1, 2008 Medicare will stop paying forobjects retained during surgery. Several major insurersare following suit.

By helping prevent the occurrence and risk of retainedsurgical objects, the RF Surgical Detection System sets anew standard of patient care and safety in the operatingroom and helps you avoid the cost of diagnosis, treat-ment, re-operation, legal settlement and the time trackingOR disposables.

Developed and Manufacturedby RF Surgical Systems, Inc.The RF Surgical Detection Systemis exclusively distributed byMedline® Industries, Inc.

For more information, contactyour sales representative or call1-800-MEDLINE.

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Searching for thatone last sponge?

Reference1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and healthstatistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.(PHS) 2001-1250 1-0287.).

a


Performing surgical counts accurately and efficiently is oneof the first things taught to perioperative professionals.9

Everyone involved in the surgical procedure shares an ethical,moral and legal responsibility to provide the patient with thesafest possible care. This includes assuring that no foreignobjects are retained where they can cause pain, harm,further surgery or even death. To do this calls for the followingguidelines set up by the American College of Surgeons to befollowed:2• Effective communication among perioperative staff• Consistent application and adherence to individual facility

standards for counting procedures• Performance of a methodical wound exploration prior to

closure of the surgical site• Use of X-ray detectable items in the surgical site• Maintenance of the most optimal OR environment possible

to allow for focused performance of tasks• Use of X-ray and RF technology as indicated to ensure

there are no items remaining in the surgical field

There are many variables during thecount process that can potentiallylead to errors related to retainedforeign objects.

These include trauma situations, sudden changes in patientstatus, obesity, noise and traffic in the room and staff changesintraoperatively. However, it is still the number one priority ofall members of the surgical team to ensure the patientʼssafety. OR personnel must utilize their knowledge and experienceand remain diligent and focused during the counting phasesof the surgical procedure so that no patient has to suffer froma retained item.3

About the authorMegan Giovinco, RN, CNOR, RNFA, currently a clinical nurseconsultant, has been an RN for more than 10 years. Previously,she worked as a nurse at a number of acute care facilities andtrauma centers.

References1 Brown M, Schabel S. Retained laparotomy sponge. Applied Radiology.2004;33(1).2 Cedars- Sinai: OR Elimination of Retained Foreign Objects Taskforce. Nothing leftbehind. Available at: www.csmc.edu/11749.html. Accessed July 18, 2008.3 Jackson S, Brady S. Counting difficulties: retained instruments, sponges andneedles. AORN Journal. 2008;87(2):315-321.4 Gibbs VC, McGrath MH, Russell, TR. The prevention of retained foreign bodiesafter surgery. Bulletin of the American College of Surgeons. 2005;90(10).5 Brandon G. Rule denying payments for “never events” will force a close look atcurrent practice. AORN Management Connections. October 2007:3(10).6 The Joint Commission International Center for Patient Safety. Reducing the risk ofunintentionally retained foreign bodies. Available at:http://www.jcipatientsafety.org/15199/. Accessed July 18, 2008.7 RF Surgical Systems Inc. Retained surgical objects: costly to avoid and over-come… until now. Available at: www.rfsurg.com/retainedobjects.htm. Accessed July18, 2008.8 American College of Surgeons. [ST-51] Statement on the Prevention of RetainedForeign Bodies after Surgery. Available at: http://www.facs.org/fellows_info/state-ments/st-51.html. Accessed July 18, 2008.9 Murdock DB. Trauma: when thereʼs no time to count. AORN Journal. February2008:87(2):322-28.10 RF Surgical Systems Inc. Features. Available at: http://www.rfsurg.com/fea-tures.htm. Accessed July 18, 2008.

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To improve surgical safety worldwide,the World Health Organization (WHO) hasreleased a new safety checklist for surgicalteams to use in operating rooms, accord-ing to a report regarding the Safe SurgerySaves Lives initiative, published onlineJune 25 in The Lancet and also availableon the WHO Web site. These WHO guide-lines and checklist are the first edition, andthey will be finalized for dissemination by late2008, after completion of evaluation in 8 pilotsites globally.

"Preventable surgical injuries and deaths are now a growingconcern," Margaret Chan, MD, director-general of WHO, saysin a news release. "Using the Checklist is the best way toreduce surgical errors and improve patient safety."

High mortality and morbidity of major surgical procedures mandateglobal public health and surveillance measures to improvesurgical safety, especially in low-income areas with limitedsurgical access. Estimates suggest that about half of surgicalcomplications may be preventable.

The Safe Surgery Saves Lives initiative, a collaboration of morethan 200 national and international medical societies andministries of health led by the Harvard School of Public Health,aims to reduce avoidable surgical mortality and morbidity. Thenewly developed WHO Surgical Safety Checklist provides a setof surgical safety standards applicable to all countries andhealth settings.

At 8 pilot sites worldwide, preliminary findings from 1000patients suggest that using the checklist has nearly doubled the

likelihood that patients will receive a higherstandard of surgical care, with adherenceto these standards improving from 36% to68%, and to nearly 100% in some hospitals.Better adherence has been linked tosignificant reductions in surgical morbidityand mortality, although final results are notyet available.

The checklist covers 3 phases of a surgicalprocedure: before anesthesia is induced,before skin incision, and before the patientleaves the operating room. For each phase,

a checklist coordinator confirms that the team has com-pleted the designated tasks before the next phase of theoperation occurs.

World Health Organization IssuesSafety Checklist for Surgical Teams

By Laurie Barclay, MD andBrande Nicole Martin

Patient Safety

Before induction of anesthesia, key components of thechecklist, using the mnemonic "Sign In," are as follows:

• Check that the patient has confirmed their identity, thesurgical site, and the procedure to be done and that thepatient has given informed consent.

• The surgical site should be marked, if applicable.• The anesthesia safety check should be completed.• The pulse oximeter should be placed on the patient

and functioning.• Check to see if the patient has (1) A known allergy. If so, these

should be documented. (2) An anatomically difficult airway tointubate or aspiration risk. If so, additional equipment andassistance should be available. (3) Risk of more than 500-mLblood loss in adults or 7 mL/kg in children. If so, provisionshould be made for adequate intravenous access and fluids.


Before skin incision, the checklist uses the mnemonic"Time Out" for the following components:

• Confirm that all team members have introduced themselvesboth by name and by their role on the surgical team.

• The surgeon, anesthesia professional, and nurse shouldverbally confirm the patient's identity, surgical site, andprocedure to be performed.

• Anticipated critical events to be reviewed by the surgeonare any critical or unexpected steps, estimated operativeduration, and anticipated blood loss.

• Anticipated critical events to be reviewed by the anesthesiateam are whether there are any patient-specific concerns.

• Anticipated critical events to be reviewed by the nursing teamare confirmation of sterility of the tools, supplies, and field(including indicator results); documentation and discussionof any equipment issues or concerns; whether antibioticprophylaxis has been given within the last 60 minutes, ifapplicable; and whether essential imaging is displayed,if applicable.

Lancet. Published online June 25, 2008. Reprinted with permission.

World Health Organization. Implementation Manual WHO Surgical SafetyChecklist (First Edition). Available at: http://www.who.int/patientsafety.

Before the patient leaves the operating room, thechecklist uses the mnemonic "Sign Out" for thefollowing components:

• The nurse verbally confirms with the team the name of theprocedure to be recorded and verifies instrument, sponge,and needle counts, if applicable; labeling for the surgicalspecimen, including patient name; and whether there areany equipment problems to be addressed.

• The surgeon, anesthesia professional, and nurse reviewthe key concerns regarding recovery and management ofthe specific patient.

The WHO notes that the checklist is not intended to becomprehensive but encourages specific modifications andadditions appropriate for each local practice.

"Surgical care has been an essential component of healthsystems worldwide for more than a century," says checklistcoauthor Atul Gawande, MD, MPH, a surgeon and professorat Harvard Medical School in Boston, Massachusetts."Although there have been major improvements over the lastfew decades, the quality and safety of surgical care has beendismayingly variable in every part of the world. The SafeSurgery Saves Lives initiative aims to change this by raisingthe standards that patients anywhere can expect."

A copy of The WHO Surgical Safety Checklist can be found on Page 86


We hear a lot about culture change in health care thesedays. Terms like “culture of safety,” a “just culture,” a “safetyculture” or the “culture of a high-reliability organization” pepperthe conversations of folks talking about patient safety and howto improve it. Just what is culture and how do you go aboutcreating the culture you want?

Moments of TruthHow to enact aculture change

at your facility

By Stephen W. Harden


Defining cultureThere are numerous definitions of culture. Everyone seemsto have their own take on it.After working with over 80 healthcareorganizations in the past eight years to help them create andsustain a culture of safety based on the best practices ofhigh-reliability organizations, I have come to believe thedefinition of culture is this: “The cumulative effect on theorganization of the actions of the people within the organizationat daily moments of truth.”

The heart of this definition is what people do at the dailymoments of truth. Intrinsically, you know what a moment oftruth is – the tens, if not hundreds, of little decision pointsevery healthcare professional encounters in the course oftheir daily activities. A decision point is where a choice mustbe made. You can do “A” or “B.” You can do something ornothing. You can say something or say nothing. You can doit the right way or use a work-around. You can do it mindfullyor thoughtlessly. Many of these decisions are decided almoston the subconscious level, sometimes out of habit – withouteven being aware of deciding.

The formula for culture changeSo if we want to change culture, then we must influence whathappens at the thousands of daily moments of truth in anorganization. There is a simple formula for this. Rememberthat “simple” does not always mean “easy.” This formula issimple to understand and difficult to follow. The formula forchanging culture is this:

Thoughts + Actions + Habits + Character = Culture

Changing culture begins with changing how folks think at themoment of truth. If you can change how they think, affect whythey do what they do, then you can change how they act atthe moment of truth. If we can change their thinking longenough to affect how they act on a repetitive basis, then wecan help them develop habits. Habits are those actions wetake almost without thinking – itʼs just the way we “do busi-ness” on a personal level. Changing habits changes our char-acter. Character is what we do, again almost at thesubconscious level, especially when we think no one iswatching or no one will know.

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Ultimately, culture is determined by the collective characterof all of the people in the organization. Their character isdetermined by their habits. Their habits are determined byhow they repeatedly act at moments of truth. Their actions atthat moment are determined by how their thought processeshave been influenced. So if you want to change culture, youmust change character, and if you want to change characteryou must change habits, and if you want to change habitsyou must change repetitive actions, and if you want tochange actions you must change how people think.

In my experience, the most effective way to change howpeople think is through leadership actions. These actionsinclude steps such as:

• Over-communicating what must be done, how it must bedone and why it must be done;

• Aligning all of the documents that describe how businessis done in the organization with the philosophy of howit should be done;

• Public and repetitive acknowledgment and rewardingof the desired actions at the moments of truth;

• Consistent coaching for those needing improvement andwilling to improve and

• Imposing negative consequences for those unwilling tochange how they think and act.

To change how people act at the moment of truth, training ismost effective. “Telling” is not training. Great training thatchanges actions is experiential, inter-disciplinary, case study-based, allows for practice and offers real-time feedback andreinforcement on performance. Effective training gives boththe individual and the team an opportunity to practice the

Leading a Change Initiative

"Your success in life isn't based on your ability to simplychange. It is based on your ability to change faster thanyour competition, customers and business."- Mark Sanborn

Questions to ask when considering change:• What do we want to change?• Why do we want to change?• How are we going to change?• Will change make things better?

Often, change does not bring about the desired out-come, or is only temporary. Permanently changing theculture of an organization requires taking the rightsteps in the right order.

Is your team resistant to change? Listed below arethree key components required to leading an effectivechange initiative:

1.Planning - Leading a change initiative requires acompelling vision, a plan to achieve that vision,and time to implement the plan. Anticipate potentialobstacles and plan for overcoming or avoiding them.Achieve sustainability by anchoring your changesinto your organization's culture. Don't forget toschedule in short-term win opportunities withinyour long-term planning. This will encourageforward movement.

2.Training - Provide training and support duringimplementation. Plan for training of new-hires andstaff turnover as this will help to ensure sustainability.Make certain the proper equipment is available tosupport your change initiative. You can't successfullyrun a new software program system-wide when mostof your team is still using dinosaurs for computers.Avoid regression by celebrating the "battle won" toosoon, but celebrate your teams' successes along theway as this will build confidence.

3.Human power - Are you adequately staffed to leadthis change initiative? Do you have champions inplace? Are your champions equipped with a commonvision? Avoid overburdening an already overburdenedteam. Consider restructuring and adding new teammembers to better ensure change and desiredoutcome.

Reprinted with permission from LifeWings. To learnmore, visit www.saferpatients.com.


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References1 Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386.

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

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actions needed in a learning environment so they will skillfullybe used at the moment of truth.

To ensure those actions are repeatedly used when neededand therefore made into a habit, hardwired tools are mosteffective. Tools such as checklists, protocols, communicationscripts, standardized communications and briefing guideshelp people use the right action at the right moment. The toolsserve as a forcing function: if the tool is used correctly as partof the consistent daily work flow, the individual has no choicebut to take the right action repeatedly and thus develops aneffective habit.

Little by little, moment by moment, person by person, habitsare ingrained and character changes. When characterchanges, the culture will change. Simple, but not easy. Thebeauty of the LifeWings methodology is that each of thecomponents necessary to affect thinking, actions and habitsare built into our process and our expert facilitators andcoaches demonstrate and teach the skills to follow theculture changing formula.

Perhaps your initiative will become guided by this quote fromThomas Carlyle:“Culture is the process by which a personbecomes all that they were created capableof being.”

As you and I together continue to create and sustain cultureswhere healthcare professionals are allowed to be capable ofall they were created to be, we will truly change the patientsafety landscape in this country.

About the authorStephen W. Harden is President of LifeWings Partners LLC andco-founder of Crew Training International, Inc. (CTI), the parentcompany of LifeWings. Prior to his position at LifeWings, he wasthe principal courseware designer of CTIʼs Crew ResourceManagement (CRM) training for the U.S. Air Combat Command,Air National Guard, Air Force Reserve Command, Italian Air Force,Swiss Air Force, Belgian Air Force, domestic and commercialairlines, construction crews and hospital surgical teams.

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Postoperative surgical site infections, also known as SSIs, arequickly becoming the most common type of nosocomialinfection in patients undergoing surgery. They can lead toincreased morbidity, mortality, length of hospital stay and healthcarecosts.1 These infections number approximately 500,000 per year,among an estimated 27 million surgical procedures.2 Postoperativesurgical site infections account for about one quarter of the estimated2 million nosocomial infections in the United States annually.3

Everyone has a part to play in preventionPostoperative surgical site infections are not to be taken lightly.The occurrence and nature of SSIs vary from facility to facility, surgeonto surgeon as well as from patient to patient. For the operatingroom team, the warlike struggle against SSIs is complex. Eachteam member caring for the surgical patient plays an important rolein the prevention of postoperative surgical site infections. Surgicaltechnologists, nurses, anesthesia care providers and surgeonsalike can greatly impact the outcome of each surgical procedure byfollowing the structured protocol proven to prevent postoperative sur-gical site infections.

The surgical technologistSurgical technologists have the primary responsibility for main-taining the sterile field and remaining vigilant in verifying that allmembers of the team adhere to an aseptic technique.4 Without thisconstant vigilance by the surgical technologist, the occurrence ofinadvertent contaminations could go unnoticed and ultimately leadto a postoperative surgical site infection. The dedication of the surgicaltechnologist to uphold this responsibility is known as a “surgicalconscience.” A surgical conscience is defined as “the ethical andprofessional motivation that regulates oneʼs aseptic technique.”5

Along with a surgical technologistʼs close watch over the operativefield, the tech must be aware of which surgical procedures requirea clean and dirty instrument setup. For example, in a procedureinvolving the gastrointestinal tract, the surgical technologist ispresented with the challenge of maintaining a clear definitionbetween instruments involved with the contaminated portion of theprocedure and the portion of the procedure that must remain sterile.In order to do so, the surgical technologist must provide the membersat the surgical site with a sterile basin dedicated to the reception ofthe contaminated instruments just before the surgeon opens thebowel.6 Throughout the duration of this portion of the procedure, itis imperative that the surgical technologist does not come in contact

with the instruments intended for use after the anastomosis is completed.

This technique requires knowledge of anatomy as well as exceptionalorganizational skills. A surgical technologist with a healthy surgicalconscience and a general understanding of the surgeries in whichthey partake is a valuable team player in the fight against SSIs.

The circulating nursePrior to undergoing a surgical procedure, the patient is prepared forsurgery by the circulating nurse. This preoperative routine carriedout by the circulating nurse often involves hair removal anddecontamination of the surgical site. It is believed that preoperativesurgical site hair removal reduces infection rates; in contrast, somemethods of surgical site hair removal have been found to increasethe likelihood of SSIs.7 For this reason, healthcare facilities havebegun using electrical clippers verses the old-fashioned method ofdry shaving with a razor.

In addition to hair removal, the circulating nurse is most oftenresponsible for the decontamination of the patientʼs skin with anantiseptic solution. The purpose of the skin preparation is toreduce and ultimately remove pathogenic transient microorganismsfrom the epidermal and dermal surfaces.5 The Association of peri-

Are you playing your partin prevention?

Surgical SiteInfections

Surgical technologists, nurses,anesthesia care providers and surgeonsalike can greatly impact the outcomeof each surgical procedure by followingthe structured protocol proven to preventpostoperative surgical site infections.

By Dayna Lowe, CST Instructor


Operative Registered Nurses statesthat when selecting antisepticagents, one should take intoconsideration the types of tissueinvolved. AORN emphasizesthat one should choose an agentwith a broad range of germicidalaction and also apply it in accor-dance with the manufacturerʼswritten instructions.

The circulating nurse also plays a crucial role in maintaining thepatientʼs body temperature, which can greatly influence the riskof SSIs. Although it seems more of a courtesy than structuredprotocol, the provision of warm blankets can ensure the patientʼscore temperature is at the homeostatic state at the timeof induction.

The anesthesia care providerAttention to the patientʼs body temperature is a standard of carein anesthesia management. Operating rooms are kept at acool temperature because it has long been believed thatdoing so minimizes the risk of infection. Recent studies suggestthat this is not the case at all. Lowering the core body tempera-ture causes dermal vasoconstriction and reduced blood flow tosurgical sites, thus taking away life-sustaining oxygen.8 Bothregional and general anesthesia can cause the bodyʼs coretemperature to drop. In an attempt to prevent intraoperativehypothermia, the anesthesia care provider often employs theuse of a forced-air warming blanket.

Another action the anesthesia care provider takes that aids inthe patientʼs ability to avoid an SSI is the administration of theprophylactic antibiotic(s) in a timely manner. In fact, two nationalorganizations, the Centers for Disease Control and Prevention(CDC) and the American Society for Health System Pharmacists(ASHP), have recently collaborated to provide medical caregiverswith guidelines regarding the administration of prophylacticantibiotics for a variety of procedures.9,10 Administration ofantibiotics, usually intravenously, should be timed so that a bac-tericidal concentration is present in blood and tissues by the timethe surgical incision is made and maintained until closure of thesurgical site. Because of the overwhelming positive impact of thestudies done on the administration of prophylactic antibiotics, it isnow a standard of care and recommended practice in mosthealthcare facilities.

In addition to the responsibilities discussed above, the anes-thesia care provider is accountable for monitoring the patientʼsblood oxygen saturation. Decreased oxygen levels devital-ize tissue and increase the risk for bacterial colonization.11

Providing the patient with an oxygen supplementation involvesthe delivery of 80 percent oxygen and 20 percent nitrogenthrough the use of an endotracheal tube, a sealed mask, amanifold system or a conventional non-rebreather mask for thefirst two hours of recovery. Oxygen is increased to 100 percent

immediately before extubation,with the concentration returned to80 percent by the anesthesiologist.12

The surgeonThe surgeon is the individual mostresponsible for prescribing thepreoperative antibiotics. Preoper-ative administration of antibioticsis a course in prevention. Therationale suggests that if there is

an infusion of antibiotics in the tissue prior to incision, there isless of an opportunity for opportunistic bacteria to find a homein the patientʼs surgical incision. An intricate combination oftiming, selection, duration and discontinued use is vital to thesuccess of an antibiotic.

In a successful surgery, each individual team member plays animportant role. Although certain tasks and preoperative routinesare delegated to the staff, a system of accountability is useful tomaintain an ideal approach to preventing SSIs. A medicalcaregiverʼs continued education in the advances in aseptic tech-niques, and overall prevention of surgical site infections, canhelp ensure a smooth, infection-free recovery for the patient.

About the authorDayna Lowe has been a surgical tech-nologist for six years. She currently worksat a smaller hospital in Florida and as anInstructor of Surgical Technology at CentralFlorida Institute.

References1 Perl T. Identification of Risk Factors Associated with Surgical Site Infection following Spinal Sur-gery. Study currently underway at Johns Hopkins University.2 Centers for Disease Control and Prevention. National Center for Health Statistics. DetailedDiagnoses and Procedures, National Hospital Discharge Survey, 1994. Hyattsville, Md.: Departmentof Health and Human Services; 1997.3 Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infectionrate: a new need for vital statistics. Am J Epidemiol. 1985;121:159-67.4 Commission on Accreditation of Allied Health Education Programs. Surgical Technologist. Avail-able at: http://www.caahep.org/Content.aspx?ID=53. Accessed July 1, 2008.5 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. St. Louis, Mo.: Elsevier Saunders;2005.6 Alexander FM. Maintaining a sterile field during gastro-intestinal surgery. The American Journalof Nursing. 1952;52(6):705-07.7 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004122.8 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.N Engl J Med. 1996;334:1209-15.9 American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobialprophylaxis in surgery. Am J Health Syst Pharm.1999;56:1839-88.10 Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices AdvisoryCommittee. Guideline for prevention of surgical site infection. Am J Infect Control. 1999;27:97-132.11 Hopf HW, Hunt TK, West JM et al. Wound tissue oxygen tension predicts the risk of wound in-fection in surgical patients. Arch Surg. 1997;132:997-1004.12 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce theincidence of surgical-wound infection. Outcomes Research Group. N Engl J Med. 2000;342:161-67.

THESE INFECTIONSnumber approximately

500,000 per year, amongan estimated 27 millionsurgical procedures.2


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Great Ideas from Your Peers

Surgical Skin Prep Solutions

At St. Vincentʼs Medical Center in Indianapolis, Indiana,Paul Durgan, staff educator for surgery, came up withan innovative way to assist surgical personnel inproviding the most effective prep solution in anefficient and cost-effective manner. Paulʼs goals wereto offer a high-efficacy surgical prep solution while simul-taneously reducing the waste associated with the facilityʼscurrent prep kit. He had observed staff membersdiscarding most of the contents in their current preptray and adding their preferred solution.

The CDC strongly recommends using 2 percent chlorhex-idine (CHG) solution for skin antisepsis. Two percentchlorhexidine solution has been shown to be six timesmore effective than alcohol and povidone-iodine incleaning the skin and in inhibiting microbial growth fordays afterward.1 In two studies measuring persistentefficacy, chlorhexidine demonstrated significant residualantimicrobial effects for five days and was more effectivethan isopropyl alcohol, alcohol or povidone-iodine alone.1

Paul had the opportunity to attend a seminar in which Dr.Allan Morrison Jr., an epidemiologist and chairperson ofInfection Control at Inova Fairfax Hospital and clinicalassistant professor at Georgetown University Hospital,discussed the benefits of chlorhexidine as a surgical prep

solution, particularly as it relates to reducing facility-acquired infections following surgical procedures.

This led to the idea of creating a custom surgical prep traythat only contained supplies that could be used in almostevery procedure. Of course, Paul wanted to be sure thatchlorhexidine was the preferred prep solution, so theychoose a four-ounce bottle containing 4 percent CHG.Additional components in the tray include 100 ml saline(for diluting or rinsing), three sponge sticks, six wingedsponges, two cotton swab applicators, two blue cloth towelsand two white cloth towels. They chose cloth towels forbetter absorbency and also because they have much lessmemory than a paper towel, which can spring back afterplacement and lead to cross contamination.

Because CHG cannot be used to prep eye, ear or genitalprocedures, the need for additional prep solutions is appar-ent. Paul is actively searching for a CHG prep that can beused on genital areas and will let us know when he findshis next solution.

By The OR Connection staff

Creating a custom surgical preptray enabled St. Vincent’s to realizea 29 percent cost savings over theirprevious trays. They lowered theirper-tray cost by $2.78.


St. Vincentʼs orthopedic department has also recentlyinitiated a study with their total joint patients, asking themto shower with CHG the night before their surgery. TheCDC also recommends that surgical facilities requirepatients to shower or bathe with an antiseptic agent atleast the night before surgery.2 Additional information willbe shared as the results of this study become available.

Improved efficiency, decreased waste, better patient careand cost savings are all the results of one innovativechange. Whereas there is often a perception thatcustomization leads to increased cost, when you find thatstandardized solutions result in throwing away suppliesthat are not wanted or used, one can easily see wherecustomization can provide a cost effective solution.

Paul Durgan has been the staff educator for surgery at St.Vincentʼs Medical Center in Indianapolis, Indiana, since 2005.Paul says that this position has helped him “attain a broaderperspective of current needs for patient care as well as physicianand associate satisfaction.” He credits the development of theCHG prep kit as an area in which he was able to promote a cost-effective solution to one of his facilityʼs needs.References1 Hibbard J et al. A clinical study comparing the skin antisepsis and safety ofChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. Journal ofInfusion Nursing. 2002;25(4):244-49.2 Nichols RL. Preventing surgical site infections: A surgeon's perspective.Emerging Infectious Diseases. 2001;7(2).

Components of the Custom Surgical Prep Tray• Four-ounce bottle of 4 percent CHG• 100 ml saline (for diluting or rinsing)• Three sponge sticks• Six winged sponges• Two cotton swab applicators• Two blue cloth towels• Two white cloth towels.

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After a leisurely lunch in the outdoor café, Sandy and Joechecked their afternoon assignment. They were to relievethe staff in OR 31. Sandy and Joe entered the OR through thesterile core as the surgeon was initiating the time-out. Joeopened his gown and gloves while Sandy received report fromthe circulating nurse. The patient was a young anorexic womanwith no known allergies who was undergoing a right thora-coscopy and chemical pleurodesis for recurrent pneumothorax.She was positioned in a lateral position right side up on abean-bag positioner. A towel roll was placed under her axilla.Her arms were padded with foam and pillows and secured onarm boards with two pillows placed between her legs. She wassecured to the OR bed by a safety strap across her thighs aswell as tape across her hips.

After he was gowned and gloved, Joe handed Sandy the lightand camera cords. The surgeon asked for the room lights to be

dimmed and then the case was underway. This will be a quickcase, Sandy thought to herself as she opened the vial of steriletalc to the field. She finished her computerized charting and,within what seemed like minutes, Joe was ready to do the firstclosing count. After they completed their counts, Sandy openedthe chest drainage tubing to the sterile field and filled the chestdrain with water. The second counts were completed soon afterand Sandy called for moving and lifting help as Joe placed thedressings over the small incision sites.

Joe removed the drapes from the patient as the surgical assis-tants brought the stretcher into the room and stood at the sideof the operating room table in preparation for repositioning ofthe patient for extubation.

Joe asked Sandy to step around to his side of the OR bed. Hepointed to an area where a portion of the draw sheet covering

Flipping the Switch on PressureHow to help reduce your patients’

pressure ulcer risk

By Jayne Barkman, RN, CNOR

Patient Safety


the bean-bag positioner hadshifted during the procedure andthe decompressed bean bagwas pressed directly against thepatientʼs skin. The standard ofcare at their hospital for lateralpositioning of patients includedplacing foam padding betweenthe patient and the bean bag aswell as placing a gel roll underthe axilla and foam padding under the patientʼs heels. After thebean bag was compressed to reposition the patient, Sandy andJoe assessed the patientʼs skin. A three-inch-long reddenedarea was noted along the patientʼs mid-thoracic spine wherethe bean bag had come into direct contact with the skin.

When the anesthesiologist was ready, the patient was lifted andplaced in a supine position. Sandy assisted the anesthesiologistwith extubating the patient and asked Joe to assess thepatientʼs ankles and feet for any pressure areas. Joe noted aquarter-sized reddened area on the patientʼs left lateralmallelous. When the patient was rolled onto her right side toplace the transfer device under her, Sandy noticed a plum-sizedreddened area below her left axilla, yet another pressure area.The patient was lifted onto the stretcher and transported to theCVICU. When relaying report to the CVICU nurse, Sandypointed out the reddened areas on the patientʼs back, left axillaand ankle as pressure points that needed close monitoringpostoperatively.

Back in the OR and helping with room turnover, Sandy and Joeshook their heads. The hospital policy clearly indicated thatfoam or gel pads were to be used to pad areas of potential pres-sure on all surgical patients.

As representatives on the patient care council, Joe and Sandywere aware that an order had been placed for additional gelrolls and pads – as these items had virtually disappeared fromthe OR – and that new pressure-free operating table mat-tresses had been ordered for each of the operating rooms toreplace the old table pads, some of which were cracked andrepaired with tape. Pressure ulcer prevention had also beenadded to the hospitalʼs required annual competency educationfor 2009. Joe suggested to Sandy that the next OR in-servicebe dedicated to an interactive positioning in-service where staffvolunteers were placed in various positions and could verballyrelay to their coworkers the areas that felt uncomfortable so thestaff had an understanding of direct areas of pressure patientsexperience when positioned during their surgical procedures.

Sandy agreed and said she wouldtalk to Sue, the director, to get thein-service scheduled as soon aspossible.

How to take the pressureoff your patientsIn the perioperative environment,nurses are presented with myriadchallenges when caring for their

patients. Careful attention is given to keeping the patientʼsbody in proper alignment when positioning in order to preventpostsurgical neuropathies. It is imperative when positioningthe patient that all potential pressure points are adequatelypadded as well. When using linens, such as blankets and towels,for rolls or positioning devices or placing a patient on a thin ORmattress, you could inadvertently be placing your patient at risk forpressure ulcer formation. Linens, which are readily available inmost operating rooms, are often used for positioning patientsbut do not reduce pressure and may result in unrelieved areasof pressure or friction injuries.1

Studies have indicated that when thepatient is unable to move duringsurgery, it is important that theweight of the patient be uniformlydistributed on a firm, stable surfacethat conforms to the patient, such asa gel or thick foam mattress pad.2

The amount of pressure and the length of time pressure isapplied to the skin are both critical factors in pressure ulcerformation. Studies have indicated that high pressure for a shorttime and low pressure for a longer duration have the sameeffect on potential tissue damage and the likelihood of pressureulcer formation.2 When pressure is applied to the skin, bloodflow is decreased, leading to potential skin breakdown andtissue necrosis.3

While extrinsic factors such as shear, force friction and pressurepredispose a surgical patient to the development of pressureulcers, intrinsic factors such as the patientʼs nutritional status,age, mobility and mental and continence status also place thesurgical patient at risk of pressure ulcer formation. Recentresearch, however, has indicated that pressure may be thesingle most important factor in the formation of pressure ulcersintraoperatively.3

IT IS IMPERATIVEwhen positioning the patient thatall potential pressure points areadequately padded as well.


Typically, perioperative nurses have no contact with the patientpostoperatively and therefore the ramifications of intraopera-tively caused pressure ulcers are unknown to the perioperativestaff. The Association of periOperative Registered Nurses(AORN) recommends doing a thorough preoperative interviewand assessment to determine the appropriate positioningdevices required for each individual patient. Their guidelinesstate that the perioperative nurse should be involved inpositioning the patient as well as monitoring for proper bodyalignment and the tissue integrity of the patient after position-ing and during the surgical procedure. A skin assessmentshould be repeated when the procedure is finished with docu-mentation of the assessment. The recommended practices alsostate that positioning policy and procedures should be acces-sible to the staff and be reviewed and revised annually.1

About the authorJayne Barkman, RN, BSN, CNOR, has 29 years of perioperativeexperience in various roles, including surgical technologist, staff nurseand clinical educator. She currently works as a clinical nurse consultant.

References1 AORN. Recommended practices for positioning the patient in theperioperative practice setting. In: Standards, Recommended Practices,and Guidelines. Denver, Colo.: AORN, Inc; 2006:587-590.2 Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention:An analysis of bedding materials. Research in Nursing & Health.1994;17(5):333-39.3 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB,Gebhart GH, Ma EK. Pressure ulcer prevention. J Long Term Eff MedImplants. 2004;14(4):285-304.4 Pressure Ulcers Risk Analysis (Healthcare Risk Control November2006). Available at: www.ecri.org/documents/patient_ safety_center/pressureulcers.pdf. Accessed July 23, 2008.5 Ankrom MA, Bennett RG, Springle S et al. Pressure-related deep tissueinjury under intact skin and the current pressure ulcer staging systems.Advances in Skin & Wound Care. 2005;18(1).6 Wilhelmi BJ. Pressure Ulcers, Surgical Treatment and Principles. Avail-able at: http://www.emedicine.com/plastic/topic462.htm. Accessed July23, 2008.

Intraoperatively Acquired Pressure Ulcers4,5,6

• Initially appear as a burn like lesion.• Occur most frequently in patients undergoing general,

thoracic, orthopedic, cardiac and vascular procedures.• Have been documented to occur in 12 percent to 66

percent of surgical patients.• Account for 42 percent of nosocomial-acquired

pressure ulcers.• Add an additional cost of up to $60,000 per patient or

750 million to 1.5 billion dollars annually.


Patient Safety


5Five pressure ulcer

factors to keep in mind

Pressure ulcers can develop within two to six hours of theonset of pressure. Incidence is over 60 percent for high-riskpatients with femoral and/or hip fractures. Elderly patients withhip fractures have the greatest incidence of new-onset post-operative pressure ulcers, which typically occur within the firsttwo postoperative days. About 70 percent of all pressureulcers occur in people older than 70 years. Have you had apatient in your OR lately who was 70 years old with a hip orknee fracture?

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

A number of these factors are out of our control, but others canbe affected positively with the appropriate tools and practices.Following is a list of five of these factors and some considerationsyou will want to examine the next time you are caring forpatients at risk for pressure ulcers.

1. AgeIt should come as no surprise that the older we are, the morefragile our skin becomes. Skin becomes thinner, drier and hasa tendency to break down easily. The elderly are also at ahigher risk for poor circulation. Clearly, these patients need tobe handled with gentle and caring hands.

Keep in mind how long you may have this patient lying on astretcher in a holding area. Ask the patient to move themselvesif possible or encourage and help move the patient if they arelying in one position for long periods of time. And pad thoseareas where pressure ulcers most commonly occur whenpatients are lying down: back of the heels, knees, buttocks,tailbone and hipbone. Same goes for when you havebrought the patient into the operating room and placedhim on the operating room bed. Proper positioning of thepatient and padding of bony prominences is vital in preventingpressure ulcers while patients are in surgery. Your facility maywant to invest in gel table pads for stretchers and operatingroom beds as well as gel positioners.

By Claudia Sanders, RN, CFA

GIMME


2. Body buildThere are two body types that are especially susceptible topressure ulcers: obese patients and extremely thin patients.Obese patients are a higher risk due to poor circulation to fattytissues. Poor circulation means less oxygen, reduced nutritionand more risk for pressure ulcers. When appropriate, be sureto use compression stockings to help with circulation and, ofcourse, assist in preventing deep vein thrombosis (DVT). Dowhatever you can to improve circulation. This may mean usingminimal sutures in the subcutaneous layer. Handle obesepatientsʼ tissues with care and consider preoperative and post-operative oxygen use.

Extremely thin patients are also at risk because there is lessfatty tissue to “cushion” them. This means their bony promi-nences are even more susceptible for skin breakdowncompared to the average-sized patient. We cannot overstressthe importance of padding these areas and padding them withcare so as to reduce friction that can lead to skin breakdown.

3. Chemical stress on woundsAs with all surgical procedures, we must first prep the areawhere the incision will be made. This requires chemical productsof one kind or another, depending on the surgeonʼs preference.Such chemicals may include povidone-iodine, hydrogenperoxide, alcohol, acetic acid or iodophors. All these chemicalshave an important part in reducing infection, but at the sametime they can contribute to skin breakdown. This is a great timeto “think outside of the box” and consider what compromisesthe patient has before choosing your preps. In conditions ofextremely compromised skin, consider rinsing with a prepsolution and monitor how hard you rub or clean the operative site.

4. Too wet/ too dry (moisture)Most of us know the story of Goldilocksʼ search for porridgeand a bed that were “just right.” Well, the skinʼs moisture needsto be “just right” as well – not too wet and not too dry. Whencaring for surgical patients, we need to help maintain thisenvironment by being mindful of the solutions we use and howwe use them. Donʼt let prep solutions “pool” on or around thepatient. Prep solution can often run down into the creases ofthe femoral, buttocks and lower back areas, not to mention theaxillary and neck areas. Do what you can to prevent this andclean these areas before sending the patient to the recoveryroom so these chemicals will not continue to sit on the skin.Be gentle with this process, especially with the compro-mised patient.

5. InfectionWhen caring for surgical patients with infection, there are extraconsiderations to keep in mind. You know your patientʼs skin isalready compromised by infection and that their immunesystem is also compromised. This compromises healing, whichcan set patients up for pressure ulcers.

To help prevent pressure ulcers from forming, position thepatient properly (and pad bony prominences), help maintaingood body temperature (keep the OR at a reasonabletemperature) and help maintain the ideal skin moistureenvironment (if necessary, use pads to help wick moisture fromthe patient). Of course, you also want to prevent crosscontamination of infection from an open wound to other partsof the body. Consider using skin barrier-type products on thesurrounding areas before prepping an infected wound.

Keep in mind that this is an area we have all dealt with at onetime or another – but with the occurrence of these pressureulcers on the rise and changes to reimbursement policies, it istime to revisit our practices.

About the authorClaudia Sanders, RN, CFA, is currently aclinical nurse specialist. She has practiced inthe medical field for more than 30 years asa surgery technologist and periopera-tive nurse.


Medline’s Pressure Ulcer Prevention Program

Systematic efforts at education, heightened awareness and

specific interventions by interdisciplinary healthcare teams

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behavioral challenges and lack of patient and family education.2

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designed to work alone or complement your existing program.

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you in your efforts to reduce pressure ulcers in your facility.

The program includes:

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• Teaching materials for you to help train your staff

• Practical tools to help reduce the incidence of pressure ulcers

• Innovative products supported by evidence-based information

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To join the fight against pressure ulcers and for moreinformation on the Pressure Ulcer Prevention Program,please contact your Medline sales representative orcall 1-800-MEDLINE.

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Join the programto reduce pressure ulcers.

The Pressure Ulcer PreventionProgram. Pressure ulcerprevention made easy.

References1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.


The History of the

SURGICALTECHNOLOGIST


The workplace is full of a wide variety of job titles andinitials to place behind your name. They often soundsignificant, but did you ever wonder where they camefrom? What caused a need for the professions (and pro-fessionals) of today? At some time, every vocation wasnew, including that of the surgical technologist. So whatspurred the need for them?

The advances in medical technology, from antibiotics toblood transfusions, have often come during times of war.This same setting fostered the need for surgical technol-ogists. Initially, the role of the nurse basically entailedassisting the surgeon during procedures. However, asvarious wars depleted nursing resources, other ways ofproviding patient care during surgery had to be explored.1

In 1939, Dr. Thomas Parran Jr. (then the U.S. SurgeonGeneral) proposed the Protective Mobilization Plan, whichpushed for the training of enlisted medical and surgical

technicians. According to this plan, schools were to beestablished at the Army Medical Center and four othergeneral hospitals for the formal education of surgical tech-nologists. Prior to this, technicians were simply trained onthe job.2

It was not until 1940 that Dr. Parranʼs plans began to beexecuted. In 1941, the first school of surgical technologywas in session. By July of 1942, 410 students wereenrolled. With the entrance of the United States into WorldWar II, there was an even greater need for surgicalpersonnel. More schools were quickly established and thenumber of “scrubs” more than doubled in order to meetthe demand of the military hospitals both at home andabroad.2

The nursing shortage worsened as the war continued andmore and more wounded soldiers were in need of care.Nurses were in great demand to staff not only local facil-

By Jennifer Bray, SST and Greg Warino, SST

OR Issues

What Does a Surgical Technologist Do?What roles do surgical technologists play on any given day?*In the OR, they• Prepare patients for surgery - draping, positioning

and establishing the sterile field• Set up surgical instruments and equipment• Gloving• Pass instruments and sterile supplies to the surgeon• Ensure the integrity of the sterile field throughout the procedure• Cut sutures• Perform surgical counts of sponges, needles, supplies

and instruments

• Prepare, care for and dispose of specimens• Apply dressings• Operate lights and suction machines• Assist with diagnostic equipment

Outside of the OR, they• Manage central supply departments• Represent surgical instrument manufacturers

and sterile supply services* Association of Surgical Technologists. The Surgical Technologist. Available at:http://www.ast.org/ads_exhibits/index.aspx. Accessed June 17, 2008.


ities but the hospitals and medical units of distantmilitary bases and battlefields as well. Because of this,more corpsmen were trained to assist surgeons duringprocedures. They were also trained to perform tasks suchas anesthesia administration, instrument preparation, aidin clamping and retraction intraoperatively and closure ofsurgical incisions. The title Operating Room Technician,or ORT, was established.1

Early educationIn the beginning, medical and surgical technologiststudents were taught together for the first month and thenseparated for their clinical instruction. Surgical technologistswere assigned to hospitalwards or a surgical service.According to the SurgeonGeneralʼs plan, the surgicalcourse was to only take twomonths. However, it wasquickly determined that moretime was needed to trainthese students effectively.In 1943, the course wasextended to three monthswith only a month of on-the-job training.2

In 1942, advanced training was offered to select individualswho had completed the surgical courses. These technol-ogists were prepared to replace nurses in the forwardcombat areas or to become instructors of future students.Most of their training was provided by nurses in the hospitalsetting. Unfortunately, despite the specialized training andservice these advanced practice technicians provided,they were never recognized by the military. This trainingceased in 1945.3

Moving into the modern daySince the infantry was depleting the Medical Corps of itsmale technologists, the department began acceptingwomen into its programs in 1943. The Surgeon Generalrequested the recruitment of even more women in 1944.So many women answered the call to duty that schools ofsurgical technology had to be expanded yet again.3

The nursing shortages caused by World War II and thewars that followed it forced operating room supervisors toquestion the need for trained non-nursing personnel toassist during surgery. In 1949, the Association of periOp-

erative Registered Nurses (AORN) was formed. Thisgroup would play a major role in the development of thesurgical technologist into a formal part of the surgicalteam.4 In 1968, AORN formed the Association of OperatingRoom Technicians (AORT) and formal training for surgicaltechnologists began at proprietary schools. AORN alsohelped establish certification credentialing for surgicaltechnologists. The AORT initiated the first certifying examand gave those who passed it the title of Certified OperatingRoom Technician (CORT).1

In 1972, the American Medical Association formallyapproved an educational program for the OR technician.

In 1978, the Association ofOperating Room Technicianschanged its name to what it isnow known as – the Associa-tion of Surgical Technologists.5

From the humble beginningsof nothing but on-the-job train-ing to a nationally recognizedassociation and credentialingcertification, the profession ofthe surgical technologist hascertainly come a long way. Inthe years since Dr. Parranʼs

original plans were developed, hundreds of schools ofsurgical technology have been established throughout theUnited States and thousands of students have graduated.Many of these students have also gone on to earn theircertification as a surgical technologist (CST), their FirstAssistant qualification (CFA) or become instructors.5 Theprofessionals who carry these initials behind their nameshave this amazing historic timeline to thank for therewarding career they have chosen.

References1 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, Pa: W.B.Saunders; 2005.2 Office of Medical History, Office of the Surgeon General. Medical Department, UnitedStates Army Medical Training in World War II. Available at:http://history.amedd.army.mil/booksdocs/wwii/medtrain/frameindex.html. Accessed June 17,2008.3 Association of Surgical Technologists. Surgical Technology for the Surgical Technologist:A Positive Care Approach. 3rd edition. Clifton Park, NY: Delmar Learning; 2008.4 Association of periOperative Registered Nurses. AORN History. Available at:http://www.aorn.org/AboutAORN/AORNHistory/. Accessed June 17, 2008.5 Association of Surgical Technologists. About AST. Available at: http://www.ast.org/abou-tus/about_ast.aspx. Accessed June 17, 2008.

Authors Greg Warino, SST and Jennifer Bray, SST arecurrently enrolled in the surgical technologist programat Central Florida Institute in Clearwater, Fla.


Now more than ever, hand hygiene compliance is crucial.

Beginning October 1, 2008, the Centers for Medicare &

Medicaid Services will no longer be reimbursing at a higher

DRG for eight hospital-acquired conditions, including

catheter-associated urinary tract, surgical site and blood-

stream infections.1 We know that hand

hygiene is the number one

line of defense against hos-

pital-acquired infections.2

There’s no such thing as

“overeducating” when itcomes to hand hygiene.

Enhance your current

strategy with Medline’s

Hand Hygiene

Compliance Program!

The Hand Hygiene Compliance Program includes:

• An instructor’s manual that takes the guesswork out of

planning lessons

• A customizable plug-and-play CD that contains

presentations, posters and more

• Forms and tools to serve as reminders and reinforcements

• A cost calculator to help you determine the cost of

prevention vs. the cost of an infection

• A rewards program to recognize those who complete

the course

• Patient and family education materials

• CE-credit courses for staff

• A how-to guide on enhancing your presentation skills

For an on-site presentation of the Hand HygieneCompliance Program and our Healthy Hands ProductBundle, contact your Medline representative or visitwww.medline.com/handhygiene.

www.medline.com

Medline’s Hand HygieneCompliance Program

References1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems andfiscal year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20,2007.

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

For all the lives you touch.


Special Feature

Itʼs ironic when you stop and think about it – hospitals areplaces where patients go to get better, yet for somehealthcare employees theyʼre also places fraught withintimidation, harassment and even violence.

The extent of the problemAccording to the Council on Surgical and Perioperative Safety(CSPS), violence in the healthcare workplace is a growingconcern and nurses are at a particularly high risk.1 Between1996 and 2000, there were 69 homicides reported in thehealth services field.2 Twenty-five of every 10,000 full-timenurses were injured in workplace assaults in 2000. In contrast,injuries due to workplace assaults occur in only two of every10,000 employees in most private-sector industries.2

As disturbing as these numbers are, it is estimated that theactual number of incidents is much higher.2 Violent incidentsoften go unreported, possibly due to the perception thatassaults are “part of the job” in the healthcare industry.2 Otherreasons for underreporting include the lack of a solid institu-tional reporting policy, the belief that reporting will not benefitthe employee and the fear that the report could be viewed byemployers as employee negligence or poor job performance.2

Violence is increasinglycommon in health care

A Place of Healing?

By Laura KuhnThe OR Connection staff writer

Many patients who are treated in hospitalsand other care facilities are at an increased

risk of exhibiting violent behavior.


Defining violence in the workplaceThe CSPS defines workplace violence and its elements in itsStatement on Violence in the Workplace1:

Workplace violence includes, but is not limited to, intimidation,threats, physical attack, property damage and sexual harassment.

Intimidation includes, but is not limited to, stalking orengaging in actions intended to frighten and coerce.

Threat is the expression of intent to cause physical ormental harm.

Physical attack is unwanted or hostile physical contact suchas hitting, fighting, pushing, shoving or throwing objects.

Property damage is intentional damage to property.

Sexual harassment is unwelcome advances, requests forsexual favors, and other verbal or physical conduct of a sexualnature, when submission to or rejection of this conductexplicitly or implicitly affects a person's employment oreducation, unreasonably interferes with a person's work oreducational performance or creates an intimidating, hostileor offensive working or learning environment.

Triggers for violence in the healthcare workplaceMany patients who are treated in hospitals and other carefacilities are at an increased risk of exhibiting violent behavior.Medical conditions associated with violent tendencies includehypoglycemia, electrolyte imbalance, anemia, hypoxia, alcoholintoxication, pain, dementia and the use of codeine, PCP,LSD and other drugs.3 However, while these factors mightmake a person more likely to behave in a violent manner, theindividualʼs tendency toward violence must still be triggered insome way.4 These triggers are referred to as “situational factors.”4

There are a number of situational factors present in hospitalsthat can contribute to violent behavior. These include poorenvironmental design, inadequate security, access tofirearms, poorly lit areas and overcrowded, uncomfortable

waiting rooms, among others.1 Violence is also more likely toerupt when facilities are understaffed, especially during mealtimes and visiting hours.1

Healthcare workers are also more likely to encounter violencewhen they work alone or directly with volatile people, espe-cially if those people are under the influence of drugs oralcohol, have a history of violent behavior or have beendiagnosed with certain psychiatric conditions.1

What can be done?Obviously, healthcare workers canʼt control which patientscome through the doors of their facilities. They can, however,have a strategy in place for preventing violence and effectivelyhalting it when it does happen.

The U.S. Occupational Safety and Health Administration(OSHA) lists the following as the five key components in theprevention of workplace violence2:

Management commitment and employee involvementManagement and frontline employees must work together asa team or committee for a violence-prevention program to besuccessful. Management must show concern for employeesafety and allocate appropriate resources. Employees mustcomply with the workplace violence prevention program andreport violent incidents promptly and accurately.

Worksite analysisA worksite analysis is a commonsense look at the workplaceto find existing or potential hazards for workplace violence. Athreat assessment team, patient assault team or similar taskforce or coordinator can assess the vulnerability of the work-place and determine the appropriate actions to be taken.

Hazard prevention and controlAfter hazards are identified through the worksite analysis,design measures should be taken (whether through engi-neering or administrative and work practices) to prevent andcontrol these hazards.

Obviously, healthcare workers can’t controlwhich patients come through the doors of theirfacilities. They can, however, have a strategyin place for preventing violence and effectivelyhalting it when it does happen.


Safety and health trainingTraining and education for both managers and employeescan ensure that all staff members are aware of potentialsecurity hazards and how to protect themselves and theircoworkers. Security personnel will also need their ownspecific training.

Recordkeeping and program evaluationRecordkeeping is crucial in tracking the effectiveness of aviolence prevention program. Examples of records anddocuments include the OSHA Log of Work-Related Injury andIllness (OSHA Form 300); medical reports of work injury andsupervisorsʼ reports for each recorded assault; records ofincidents of abuse, verbal attacks or aggressive behavior thatmight be threatening, information on patients with a historyof past violence, drug abuse or criminal activity; documenta-tion of minutes from safety meetings and records of all train-ing program, attendees and qualifications of trainers.

Employers who would like to learn more about implementingan appropriate workplace violence prevention programare encouraged to contact the OSHA Consultation Serviceat (800) 321-OSHA. You can also learn more at www.osha.gov.2

References1 Council on Surgical & Perioperative Safety. Statement on Violence in the Work-place. Available at: http://www.cspsteam.org/education/education8.html/. Ac-cessed June 19, 2008.2 U.S. Department of Labor. Guidelines for Preventing Workplace Violence forHealth Care & Social Service Workers. Available at: http://www.osha.gov/Publica-tions/OSHA3148/osha3148.html. Accessed June 19, 2008.3 Carroll V. Preventing violence in the healthcare workplace. Alabama Nurse.2004 Mar-May.

If you’re a victimThe Massachusetts Nurses Association (MNA) hascompiled a list titled “Ten Actions a Nurse Should TakeIf Assaulted At Work.” Those ten actions are5:

• Get help and get to a safe area• Call 911 for police assistance• Get relieved of your assignment• Get medical attention• Exercise your civil rights, which might include filing

charges with police• Report the assault to your supervisor• Report the assault to your union representative• Get counseling or assistance for Critical Incident

Stress Debriefing (CISD) to prevent post-traumasymptoms

• Get copies of all reports and keep a diary of events• Return to work only when you feel safe and supported

4 Cooper C, Swanson N. Workplace violence in the health sector: state of the art.Geneva, Switzerland: International Labour Office, 2002. Available at:http://icn.ch/state.pdf. Accessed June 19, 2008.5 Massachusetts Nursing Association. Ten Actions A Nurse Should Take IfAssaulted at Work. Available at:http://www.massnurses.org/health/articles/top_ten3.htm.Accessed June 19, 2008.

Joint Commission Targets BullyingOn July 9, 2008, The Joint Commission called for a crack-down on bullying among healthcare professionals, notingthat such behavior poses a serious threat to patient safetyand the overall quality of care.

In a press release titled “Joint Commission Alert: Stop BadBehavior among Health Care Professionals,” the groupannounced it will be introducing new standards requiringmore than 15,0000 accredited healthcare organizations tocreate a code of conduct that defines acceptable and unac-ceptable behaviors. These organizations will also need toestablish a formal process for managing unacceptable behavior.

The Joint Commission is recommending that healthcareorganizations take 11 specific steps to help put an end to

bullying among physicians, pharmacists, therapists, supportstaff and administrators. Among those 11 steps:

• Educate all healthcare team members aboutprofessional behavior

• Hold all team members accountable for modelingdesirable behaviors, and enforce the code of conductconsistently and equitably

• Establish a comprehensive approach to addressingintimidating and disruptive behaviors

• Determine how and when disciplinary actions should begin• Develop a system to detect and receive reports of

unprofessional behavior, and use non-confrontationalinteraction strategies to address intimidating anddisruptive behaviors

To view the press release in its entirety, please visit http://www.jointcommission.org/NewsRoom/NewsReleases/nr_07_09_08.htm.


When one thinks of the operating room, phrases like“cutting-edge technology,” “the future of medicine” and“the newest procedures” come to mind. Although this is true,comments like “This is how we have always done it” and “What?Something new to learn?” are often heard as well. While thesebarriers are hard to overcome, the OR of the future has manychampions, including Callie Craig, Team Manager and Periop-erative Clinical Educator at INTEGRIS Baptist MedicalCenter in Oklahoma City, Oklahoma.

Callieʼs passion for perioperative nursing has been evidentthroughout her eight-year tenure in surgery. She is very involvedin her facility as a member of numerous committees and councilsand was named INTEGRIS Surgery Department Nurse of theYear in 2002.

Recruitment is one of Callieʼs primary concerns. Along withserving as the co-chair of the Integris Nurse Recruitment andRetention Team, she works with her facility in a variety of waysto bring in new perioperative professionals. Callie is proud tobe a part of the many creative ways that INTEGRIS supportsboth novice and experienced nurses.

As the departmentʼs educator, Callie has a great deal ofinvolvement with “next generation” nurses and works to

Callie Craig: A Nurse HeroBy Megan Giovinco, RN, CNOR, RNFA


advocate the value theybring to the surgical arena.It was for these efforts thatshe was the recipient ofAORNʼs Next GenerationAchievement Award at the55th Congress in Anaheimearlier this year. She wasalso elected to AORNʼs National Nominating Committee, forwhich she pledges to “bring my passion for perioperativenursing and the success of [AORN].” Her passions includenot only recruitment but the promotion of overall workplacesafety, encouraging nurses to act as patient and professionaladvocates and ensuring the continued growth of AORN.

Callie is certainly no new face to AORN. As a member of theCentral Oklahoma Chapter of AORN since 2003, she hasattended Congress five times, three times as a delegate. Sheis also a member of the Educator/Clinical Nurse Specialist andLeadership Specialty Assemblies. She has served as both pres-ident and vice president of her local chapter and as a part ofthe membership and nominating committees. She is alsoactive in the Oklahoma State Council of Perioperative Nursesand has served as their president.

Throughout her career, Callie has sought to improve her practiceby continuing her education. She received her Certification forProfessional Achievement in Perioperative Nursing (CNOR)and earned her BSN from the University Of Arkansas EleanorMann School Of Nursing. Recently, she received her masterʼsdegree in Nursing Administration from the University of Okla-homa Health Science Center.

Even though Callie is seen as an advocate for the next gener-ation, she strongly believes that the “current generation” thatmakes up part of the perioperative team has a great deal tooffer. Their experience and knowledge is invaluable to the staffthey work with and the patients for which they care. Callie feels

that it is just as important toretain these perioperativeprofessionals as it is torecruit new ones.

Callie feels that the future ofthe OR depends on allgenerations of periopera-

tive professionals working together and learning from eachother: “The new nurses and techs bring the knowledge of theirrecent education and the seasoned nurses have so much ex-perience to share. They need to get to know each other.” Cal-lie encourages mentoring as a way for staff to learn from eachother. She credits her achievements to the support and coach-ing she received from her own mentor, Janet Lewis, RN, MA,CNOR, the Administrative Director of Surgical Services at IN-TEGRIS Baptist Medical Center. As a mentor to Callie, Janetʼsown passion for surgery was infectious. “She always said ʻcomewith me – I will show you how,ʼ” Callie recalls.

Callieʼs passion for education and helping others spills over intoother aspects of her life as well. She is a leader of Precept UponPrecept Bible Study. She is also a member of the Council RoadBaptist Church Womenʼs Council. She continues to help thenext generation as a community volunteer for the Junior Leagueof Oklahoma City.

Callie has been known to quote Karen Kaiser Clark, who oncesaid, “Life is change. Growth is optional. Choose wisely.” Calliehas certainly chosen to grow with the changes of her profes-sion. She believes that the opportunities are infinite in todayʼshealthcare environment. She feels that the perioperativeprofessionalʼs reputation as the authority for patient and staffsafety must continue to expand as the challenges facing themedical community as a whole are addressed. Humbly, Calliehopes that she can be an example to other young nurses.There is no question that she is not only an example but also aninspiration to all perioperative professionals.

Special Feature

Callie feels that the future of theOR depends on all generationsof perioperative professionalsworking together and learningfrom each other.


It could be the differencebetween life and death.Wrong site surgery has recently moved into the

number one position as the most frequentlyreported hospital error.1

This is despite a conscientious effort to eliminate thisproblem before it occurs. What is needed is another layerof safety...something that will improve our chances ofcorrecting the mistake before it happens.

Enter S.T.O.P. Surgical Drapes from Medline.We just made a good idea even better. S.T.O.P. (SurgicalTime Out Procedure Drape) are available in a variety ofconfigurations, and include a “S.T.O.P.” strip* across thefenestration. As a result, you can’t forget to take a timeout to verify the correct patient, procedure, side and site.Then all that is left is to hand the sticker off to the circulatingnurse to include in the medical record, documenting thatthe verification process was completed.

If you would like to receive a free sampleof the S.T.O.P. Drape system to evaluate foryourself, ask your Medline representative orcall us at 1-800-MEDLINE.

www.medline.com

STOP!!!

Perform “TIME OUT” Verify correct:

Person

Procedure

Site & Side

Date: ______ Time: ______

Surgeon’s Initials: _____

S

mrofrrfePreV

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!!!POTS

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S.T.O.P. strip and sticker

S.T.O.P. for Safety.

References1 The Joint Commission. The Statistics page. Available at: http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.

S


The greatest obstacle to successThe fear of failure is the single greatest obstacle to success inadult life. Taken to its extreme, we become totally preoccupiedwith not making a mistake, with seeking for security above allother considerations. The experience of the fear of failure is inthe words of “I canʼt,” “I canʼt.” We feel it in the front of the body,starting at the solar plexus and moving up to the rapid beating ofthe heart, rapid breathing and a tight throat. We also experiencethis fear in the bladder and in the irresistible need to run to thebathroom.

The fear of rejection holds you backThe second major fear that interferes with performance andinhibits expression is the fear of rejection. We learn this when ourparents make their love conditional upon our behavior. If we dowhat pleases them, they give us love and approval. If we do some-thing they donʼt like, they withdraw their love and approval–which we interpret as rejection.

The roots of a Type A behaviorAs adults, people raised with conditional love become preoc-cupied with the opinions of others. Many men develop TypeA behavior that is characterized by hostility, suspicion and anobsession with performance to some undetermined high stan-dard. This is expressed in the attitude of “I have to,”“I have to,” and is associated with thefeeling that “I have to work harder andaccomplish more in order to pleasethe boss” who has becomea surrogate parent.

The most common trapMore than 99 percent of adults experience both these fears offailure and rejection. They are caught in the trap of feeling,“I canʼt,” but “I have to,” “I have to,” but “I canʼt.”

The key to peak performanceThe antidote to these fears is the development of courage,character and self-esteem. The opposite of fear is actually love,self-love and self-respect. Acting with courage in a fearful situa-tion is simply a technique that boosts our regard for ourselves tosuch a degree that our fears subside and lose their ability toaffect our behavior and our decisions.

Action exercisesHere are two things you can do to increase your self-esteem andself-confidence and overcome your fears.First, realize and accept that you can do anything you put yourmind to. Repeat the words, “I can do it! I can do it!” whenever youfeel afraid for any reason.Second, continually think of yourself as a valuable and importantperson and remember that temporary failure is the way you learnhow to succeed.

Reprinted with permission from www.mercola.com.

By Brian Tracy

Caring for Yourself


How to Thrive ina Tough Economy

By Wolf J. Rinke, PhD, RD, CSP

Unless you are on another planet, it is likely that your organization has already gonethrough several “downsizings” or “rightsizings,” as your boss might like to call them.

Time to get depressed, right? Wrong!


Time to put yourself in the driverʼs seat of your career bydeveloping new skills that will enable you to take advantageof the opportunities that are unfolding before your veryeyes – opportunities that will enable you to not only survive,but thrive in this tough economy.

Think projectsOld organizations were organized by departments andposition titles. Today, projects accomplish most work. Tothrive in a project environment, recognize that work getsdone primarily by three distinct specialties. First, there arethe resource providers. These are the folks who developand supply talent or money. Your human resource manager

and financial officer would fit into this category. Next are theproject managers. They are responsible for making surethat the talent and resources are organized in such a waythat the project gets done. Next is the talent. These are thepeople who have the skills to get the job done, such asnurses, OR techs and other front-line healthcare profes-sionals. To thrive in this tough economy, it is important thatyou master “winning management” skills so that you canperform equally well in the project manager or resourceprovider role. (For details read my Winning Management:6 Fail-Safe Strategies for Building High-PerformanceOrganizations book.)

Think globalGlobalization is accelerating at a nanosecond pace. To takeadvantage of globalization, you must dramatically increaseyour cultural awareness. If you are now employed in aprimarily “homogeneous” organization and are not at least90 percent satisfied, seek employment in a multiculturalorganization. Donʼt know where to start? Get a copy ofFortuneʼs latest issue of either 100 Best Companies to WorkFor (typically published in February) or Americaʼs MostAdmired Companies (typically issued in March of everyyear) and apply to any of the companies listed. Want to stayin health care? Not a problem, there are many on either list.For example, Methodist Hospital System is in the number10 spot on the 2008 100 Best Companies to Work For andManor Care is in the number one spot for the HealthcareMedical Facilities Group in the 2008 Americaʼs MostAdmired Companies.

Equally important, learn a foreign language. If youʼre notfluent in at least one foreign language, you will be in trouble

Special Feature


real soon. And put your languageto work by traveling to a countrythat speaks the language of in-terest to you. Youʼll really learn tospeak it, become culturally sen-sitive whether you want to or notand will bring back a ton of great ideas to accelerate yoursuccess curve dramatically.

Become an effective team player and leaderLike it or not, teams are the way lots of work is beingaccomplished in todayʼs organizations. Being effective inthis environment requires that you learn how to empowerothers and master leadership and winning managementskills, and be equally comfortable and effective in asupportive role as in a leadership role. (For more, read myDonʼt Oil the Squeaky Wheel and 19 Other Contrarian Waysto Improve Your Leadership Effectiveness book.)

Focus on delivering exceptional quality serviceDelivering exceptional quality service is not an option, butrather a survival strategy. We must be absolutely clearabout who provides us with our paycheck. No, itʼs not yourboss or even your organization. It is the person you serve –an external or internal “customer.” As a litmus test of howcustomer-focused you are, look back at your calendar forthe last week to find our how much actual time youʼve spentwith your external or internal customers. If you are notspending at least one third of your time with your “cus-tomers,” you are messing up.

Become a problem solverOne of the best ways to position yourself for advancementor pay increases is to become a problem solver. In thistough economy, you can simply no longer expect to be com-pensated for time, only for results and problems solved. Soactively look for a problem that impacts negatively on thebottom line then put a team together and solve it. Then, letothers know (especially the powers-that-be) what a greatjob your team did and how much your team improved theprofitability of your organization. If you do that consistently,you will be ready to be promoted or negotiate for anincrease in pay. (If youʼd like help with that, devour myWin-Win Negotiation CPE program.)

Think of yourselfas self-employedSeeing yourself working forone company for the rest ofyour career is, to say it gently,crazy! Itʼs just not going to

happen! In this tough economy, itʼs important that you seeyourself as “self-employed,” or “renting” your services outto someone else (your employer). To get started, pretendthat you are an entrepreneur or a consultant who is sellingservices to a client (your employer). To make this realistic,compute your daily compensation. Be sure to add about 30percent for benefits. Then get in the habit of asking yourself“Have I created value today that exceeded my daily com-pensation?” Repeat that question every day you are atwork. You may even find it helpful to place a nice-lookingsign on your work station that asks “How are you creating$_____ of value today?”

The other side of the coin is to keep asking “How have Iʻgrownʼ in my job today?” To make this happen, think ofgoing to work each day with a “briefcase” of skills and com-petencies. At the end of the day, check your briefcase to seeif there is more in it than at the beginning of the day. If, dayafter day, what you bring to work is the same as whatyou take home, itʼs is time to move on to a more challeng-ing “assignment.”

Get in the habit of asking yourself,“Have I created value today thatexceeded my daily compensation?”

Become an expert networkerOne of the most powerful skills you can develop is tobecome a highly effective networker, both inside and outsideof your organization. When it comes time to find a newassignment, your network, more than anything else, willdetermine how fast youʼll find your next dream job. To testyour networking effectiveness, ask yourself who you havebeen eating lunch with during the past week. If it is prettymuch the same people, you are missing tremendous net-working opportunities. Get in the habit of eating lunch with

IN THIS TOUGH ECONOMYyou can simply no longer expect to becompensated for time, only for results

and problems solved.


different people three out of five days a week, to sit with peopleyou donʼt know at meetings and to attend conferences thatare sponsored by groups other than yours.

Check yourselfTo assess how well you are achieving a competitive advantagein this tough economy, ask yourself the following diagnosticquestions:

Am I learning?If you are not constantly learning new things, your value inthe marketplace is diminishing rapidly.

Am I being taken advantage of?Your employer is taking advantage of you if you consistentlysacrifice your long-term development to put out short-term“fires.” Donʼt let your ego get the better of you when you arebeing told that you are so critical to the organization that “wecanʼt do without you.” Hogwash! No one is indispensable.Never, ever get caught in persistent short-term traps at theexpense of your long-term development.

If my job was open today, would I get it?Itʼs important that you “benchmark” your skills all of the time.

ASK YOURSELF...

• Am I learning?• Am I being taken advantage of?• If my job was open today,

would I get it?• Am I adding value?• Am I good at selling?• Am I energized by change?• Does my résumé focus

on contributions?


Sometimes smaller is better!

At just 15 square inches, the Medline Universal Pad with propri-

etary Safety Ring meets the same thermal performance stan-

dard as traditional electrosurgical pads up to 33% larger in

conductive surface area.

Despite its smaller size, this pad is big on safety. The propri-

etary Safety Ring allows the pad to be oriented in any direction

and also reduces corner and edge effect by more uniformly dis-

persing electrosurgical current over the entire conductive

surface of the pad.

The transthermal backing on 9100 Series electrosurgical pads

provides a barrier of moisture; it is waterproof and fluid resist-

ant. The backing allows heat to escape 25% faster than thefoam traditionally used on grounding pads, reducing the risk of

excessive heat buildup.

For more information on the impact the UniversalPad 9100 Series can have in your OR, contact yourMedline sales representative or call 1-800-MEDLINE.

www.medline.com

Small in size.Big on safety.

Manufactured by 3M

Medical Division


Electrosurgical Pad9100 Series


One way to do that is to look at the want ads to find out whatthe marketplace is looking for. If you do not possess theskills that the marketplace is looking for, itʼs time to investmore in yourself.

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

Am I good at selling?Many healthcare professionals see no need to becomeexcellent at selling. The reality is that you sell all the time.You sell your patient on getting better, you sell your boss ona raise and you sell your team members on an idea. Inaddition, you do the same at home with your spouse, childrenand even your pets. Since it is something you do all ofthe time, I recommend that you get good at it. No, wait, Irecommend you get great at it! So start looking for a qualitysales program and attend it this year!

Am I energized by change?If you are still fighting or resisting change, you are in trouble.All indications are that change will continue to accelerate at“hyper speed,” so you might as well start welcoming it.

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

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

liberate and empower you. Action will get you to grow,change and adapt. Action will provide you with virtual jobsecurity, will enable you to achieve the competitive advan-tage and assure that you thrive in this tough economy.

About the authorDr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminarleader, management consultant, executive coach and editorof the free electronic newsletters Make It a WinningLife and The Winning Manager. To subscribe, go towww.WolfRinke.com. He is the author of numerous books,CDs and DVDs including Winning Management: 6 Fail-SafeStrategies for Building High-Performance Organizations andDonʼt Oil the Squeaky Wheel and 19 Other ContrarianWays to Improve Your Leadership Effectiveness, availableat www.WolfRinke.com. His company also produces a widevariety of quality pre-approved continuing professionaleducation (CPE) self-study courses available at www.easyCPEcredits.com. Reach him at [email protected].

Angel hummed to herself as she tacked a poster on thehospitalʼs bulletin board. She heard footsteps approachingand turned to see her coworker Mary peering over her shoulderat the poster.

“Whatʼs that, Angel?” Mary asked. “Itʼs pretty. I like the pinkribbons. They match the ribbon on your lab coat!”

“Iʼm hosting a meeting for staff members to remind them howimportant it is to conduct monthly breast self-exams,” Angelexplained. “Can I count on you to be there?”

“You bet!” Mary replied. “Iʼll even bring some cookies.” Sheheaded off down the hall to visit her next patient.

Angel smiled as she smoothed out the corners of the poster.She was known for tirelessly campaigning for breast cancereducation, but very few people knew what had drawn her to

the cause. She planned to reveal that at the meeting thenext day.

Thanks to Angelʼs posters and word of mouth, the meetingroom was filled to capacity. True to her word, Mary arrivedbearing a tray of cookies. At the podium in the front of theroom, Angel was nervously shuffling a stack of note cards.She had written down what she planned to say, but as hercoworkers took their seats and started looking expectantly ather, she decided to place her notes in her pocket and simplyspeak from her heart.

“Hi, Iʼm Angel, and I know most of you,” she said. “You mighthave noticed that I spend a lot of time promoting educationabout breast cancer, and encouraging you to do monthly self-exams. What you might not know is why I care so much.” Shetook a deep breath and steadied her voice.

By Laura KuhnThe OR Connection staff writer

Angel’s Passion for Pink

Special Feature



“When I was a sophomore in college, my mother was diag-nosed with breast cancer. I spent the next six months, whatwere ultimately the last six months of my motherʼs life, at herside. I was there when she was wheeled out of surgery aftera double mastectomy. I was there when chemo caused herbeautiful hair to fall out all over her pillow. And I was therewhen she admitted to her doctor that she had never done abreast self-exam.

“My mother didnʼt know how to perform a self-exam, and shewasnʼt comfortable with the idea. She didnʼt know that therecould be outward signs of breast cancer, such as change inthe size or shape of the nipple. She didnʼt know that dimplingor puckering could be signs of an underlying problem.

“My mom didnʼt know these things, just as a lot of peopledonʼt understand the full scope of how serious a problembreast cancer still is. Weʼre making advances in early detec-tion and treatment, but this disease is by no means goingaway. In fact, more than 1.1 million women throughout theworld will be diagnosed with breast cancer this year, andmore than 410,000 of those women will die.”

Angel looked around the room and saw that the faces ofmany audience members had turned grim. She needed toinspire them, and fast!

“But thereʼs good news, too,” she continued. “Today, some-one who is diagnosed with breast cancer in its earliest stageshas a 98 percent chance of living. That rate was only 77percent in 1982. And education is helping to emphasize theimportance of screening, early education and the need formore research.”

Angel grabbed for the stack of pamphlets she had broughtwith her and began to hand them out. “These tell you how toperform a breast self-exam and give you more informationon ways you can help spread the word,” she said. “Please,take a bunch of them! Give them to your friends, your family,your patients.” She was encouraged to see that the membersof the audience were taking four or fivepamphlets as theywere passed along.

She made her way back up to the front of the room to finishspeaking. “Thank you so much for coming to this meeting. Ilost my mother to breast cancer, and Iʼll miss her every dayof my life. With your help, though, we can prevent someoneelse from experiencing that same agony. Education is trulythe key. Together, we can save lives through early detection.”

Angel smiled and was thrilled to see smiling faces lookingback at her.

Stay tuned for the continued adventuresof Medline’s family of nurse dolls, Angel,Aurora, Anastasia, Ami and Alice!

Alice Aurora Anastasia Ami

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Thechoiceis yours



Every three minutes a woman in the United States isdiagnosed with breast cancer. The chance of developinginvasive breast cancer at some time in a woman's life isabout 1 in 8.¹ These are startling statistics, but behind thesenumbers are people — sisters, daughters, mothers, grand-mothers, neighbors and friends. Any one of the 182,460women who will be diagnosed with invasive breast cancerthis year could be someone we love. Although mammo-grams are among the best forms of early detection, morethan 13 million American women over the age of 40 havenever had one.2 The Centers for Disease Control recommendthat women begin having yearly mammograms at age 40.

These facts form the foundation of Medlineʼs “Together WeCan Save Lives through Early Detection” campaign. Medlineis on a mission to change the future by taking action now.2008 marks the third year that Medline has partnered withthe National Breast Cancer Foundation (NBCF), whichprovides grants to hospitals and healthcare organizationsthat offer free mammograms for underprivileged women. Todate, Medline has donated $350,000 to the NBCF to giveback to customers and their communities, help promoteearly detection of breast cancer and ultimately save lives.

Spreading the wordTo keep early detection on everyoneʼs minds, Medlinesponsors a number of outreach projects throughout theyear and distributes several products and programs topromote awareness.

AORN breakfast forumIn March, Medline hosted a breakfast forum for 900 periop-erative nurses at the annual meeting of the Association ofperiOperative Registered Nurses (AORN) in Anaheim, Calif.Featured speaker, Dr. Marla Shapiro, author of Life in theBalance: My Journey with Breast Cancer and renownedCanadian on-air medical expert, delivered a dynamic pres-entation on coping with stress, balancing life and battlingbreast cancer. Visit www.medline.com/aorn/2008 to learnmore about the event.

Beyond the Shock® DVDMedline, in partnership with the NBCF, distributes freecopies of the DVD “Beyond the Shock,” a step-by-step guideto understanding the diagnosis of breast cancer. More than70 leading oncologists contributed to the content. To requesta copy, contact Jennifer Freedman at (847) 643-4358 [email protected].

Angel dollAngel, the second-born in Medlineʼs family of nurse dolls,promotes infection prevention and she also sports pinkscrubs and a pink ribbon to support breast cancer awareness.The Angel doll is distributed by Medline at trade shows andlarge customer events.

Pink ribbon productsMedline sells several pink ribbon products, including aBreast Cancer Awareness Rollator and bath bench, a pinkribbon lab coat and special scrubs available onscrubs123.com. A customerʼs purchase of these productssupports Medlineʼs partnership with the NBCF. Visitmedline.com or scrub123.com or contact your Medlinesales representative for more information.

For more information on Medlineʼs breast cancerawareness campaign, visit www.medline.com/bcaor contact Jennifer Freedman at 847-643-4358 [email protected]

References:1. American Cancer Society. Cancer Reference Information. “What Are the KeyStatistics for Breast Cancer?” Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp.Accessed July 15, 2008.2. The Breast Cancer Site. About Breast Cancer page. Available at:http://www.thebreastcancersite.com/clickToGive/boutbreastcancer.faces?siteId=2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.

Medline Supports Breast CancerAwareness 365 Days a Year

Together We Can Save Lives ThroughEarly Detection Breast Cancer Campaign

Caring for Yourself

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

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

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

Often, symptoms go away after your period starts.

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

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

• Take a daily multivitamin with 400 micrograms of folic acid and acalcium supplement with vitamin D.

• Exercise regularly. For safety's sake, first check with your doctor.• Eat a healthful diet that includes plenty of fruits, vegetables and

whole grains.• Avoid salt, sugary foods, caffeine and alcohol.• Try to get eight hours of sleep every night.• Don't smoke.

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

Reprinted with permission from United Healthcare

Ease the Discomfort of PMS

Caring for Yourself



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

Guacamole (4 servings)Prep time 10 minutesReady in 10 minutes

3 avocados - peeled, pitted and mashed1 lime, juiced1 teaspoon salt1/2 cup diced onion3 tablespoons chopped fresh cilantro2 roma (plum) tomatoes, diced1 teaspoon minced garlic1 pinch ground cayenne pepper (optional)

In a medium bowl, mash together the avocados, lime juiceand salt. Mix in onion, cilantro, tomatoes and garlic. Stir incayenne pepper. Refrigerate 1 hour for best flavor, or serveimmediately.

Nutritional InformationServings Per Recipe: 4Amount Per ServingCalories: 264Total Fat: 23.3gCholesterol: 0mgSodium: 601mgTotal Carbs: 16.4gDietary Fiber: 8.8gProtein: 3.7g

www. allrecipes.com

Healthy Eating


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The following pages contain practical tools for implementingpatient-focused care practices at your facility.

FORMS & TOOLS

ElectrosurgeryElectrosurgery Checklist..............................76Electrosurgical Cautery SafetyPolicy and Procedure ..................................78

Pressure Ulcer PreventionPolicy and Procedure ..................................81

Patient SafetySurgical Safety Checklist........................86

Employee SafetyManagement/Employee Checklist ..........89Employee Incident Report ......................90


Forms & Tools Electrosurgery Checklist1

Preoperative Precautions and Procedures

Physical Condition� Examine the ESU and its accessories for defects—

do not use cables or accessories with damaged(cracked, burned, or taped) insulation or connectors.

� Confirm that the ESU has been inspected for safetyand performance by a qualified BMET or clinicalengineer and that the next inspection is not yet due.

Return Electrode Contact Quality Monitor(RECQM) or Cable Continuity Alarm� Check the operation of the RECQM or the return

electrode cable continuity alarm by attempting tooperate the unit with the dispersive electrodedisconnected—the unit should not activate, and atone should sound.

Audible Activation Indicator� Activate the unit using each footswitch and

handswitch, and verify that the audible activationtone is loud enough to be heard over other noises inthe OR.

� Verify operation of any other alarms orprotective features.

Safety Holster� Position a safety holster for the active electrode in a

convenient location.

Dispersive Electrode� Use a full-surface adhesive electrode.� Inspect the electrode before placement for any flaws

or damage (e.g., discoloration, insufficient amountsof conductive adhesive).

� Confirm that the electrode's expiration date hasnot passed.

� Clean, shave, and dry the application site.� Follow the manufacturer's recommendations for appli-

cation, and ensure firm contact of the electrode withthe skin.

� Do not apply the electrode to areas where pressure isapplied to the patient (e.g., underneath the patient).

� Do not overlap sections of the electrode (e.g., whenapplying around a small limb).

� When possible, place a long edge of the electrodeclosest to the surgical site.

� If possible, do not place the dispersive electrode (oractive electrode) cables near internal pacemaker leads.

Alternate Sites� Eliminate patient contact with grounded objects

whenever possible.� If possible, remove nonvital monitoring electrodes

(e.g., esophageal and rectal probes).� Keep ECG and other monitoring electrodes as far

as possible from the surgical site and the active anddispersive electrode cables.

� Do not use needles as monitoring electrodes (theseincrease the risk of alternate site burns due to highercurrent density at the electrode site).

Prepping Agents� Avoid using flammable prepping agents or other

flammable fluids (e.g., acetone degreaser).� Avoid accumulating pools of fluids, especially near

patient electrodes.

Sparking the Active Electrode� Do not spark the active electrode to ground or to the

dispersive electrode to test the ESU.

Intraoperative Precautions and Procedures

� Minimize buildup of O2 and N2O beneath drapes andin the oropharynx.

� Activate the unit after vapors from flammable preppingsolutions and tinctures (if used) have dissipated.

� Activate the unit only when ready to deliver electrosur-gical current and only when the active tip is in view;avoid prolonged activation.

� Use the lowest effective ESU output setting; do notcontinue to increase power settings if you aren'tgetting results—look for other problems (e.g., confirmadequate placement of the dispersive electrode,check all cable connections).

Electrosurgery Checklist


� Check contact and adherence of the dispersiveelectrode each time the patient is repositioned.

� Always place the active electrode in a safety holsterwhen not in use.

� Allow only the user of the active electrode to activatethe handswitch or footswitch.

� Do not use two active electrodes on ESUs thatproduce simultaneous activation of both electrodeswhen only one switch is activated.

� Document every procedure in the OR record; includethe ESU identification number, ESU settings used(monopolar cutting and coagulation, bipolar), locationof the dispersive electrode, and the condition of theskin at the dispersive electrode site before and afterthe procedure.

� Document use and position of any other equipment(including identification numbers) used during theprocedure (e.g., hypo-/hyperthermia unit, tempera-ture probes).

Postoperative Precautions and Procedures

� Inspect the patient for injuries at the dispersiveelectrode and other sites (e.g., the sacral area—electrosurgical injuries typically appear immediatelyfollowing the procedure; pressure injuries may notshow up for as long as one or two days followingsurgery).

� Document all findings.� If any problems are noted during or after the

procedure, save all disposable items and theirpackages (so that expiration dates can be confirmed).

Courtesy of Medical Device Safety Report (MDSR) ECRI Institute, 2008.

Electrosurgery Checklist1 Forms & Tools

Regarding “Checklists...”

Worldwide, the WHO aims to have the checklist oper-ating in 2,500 hospitals in the most populous countries(with 75 per cent of the world's population) by the endof next year.

Since the 1930s, airplane pilots have run throughchecklists before taking off. Now the World HealthOrganization wants surgeons all over the globe to usethem, too.

Dr. E. Patchen Dellinger, a surgeon at the University ofWashington Medical Center in Seattle, says peopleare surprised when he tells them about the project."One of the common reactions is, 'You mean youweren't doing that before? Good heavens!'"he says.

Gawande says there's been some resistance to thelist. One London surgeon thought it was demeaning"Mickey Mouse stuff" until one day in the operat-ing room.

"Right before the incision [the medical team] took atimeout," Gawande says, "and when it came to thenurse's turn to raise any concerns, the nurse asked:'Are we really sure we have the right size kneereplacement for this patient?'"Turns out, they didn't — not anywhere in the hospital.That surgeon now swears by the surgical checklist.


Forms & Tools Policy and Procedure

PURPOSE:To provide for the safe operation of electrosurgical units, usedfor the purpose of cutting and coagulation of body tissue witha high frequency electrical current during surgical procedures.

EQUIPMENT:� Electrosurgical Generator� Electrosurgical Grounding Pad� Electrosurgical Active Electrode (Pencil)

POLICY:�� All electrosurgical generators shall meet the

performance and safety standards of the hospital.– All electrosurgical units must be approved by the

hospital Biomed.– Only electrosurgical units which are UL approved

shall be used in the operating room.– Surgical Services personnel are provided with

detailed instructions from the electrosurgical unit'smanufacturer. Operational directions are attached to each electrosurgical unit.

– Surgical Services personnel are evaluated annuallyon the safe competency form use of the electrosurgical unit and its components.

– The electrosurgical unit generator is inspectedyearly by the hospital Biomed. Dates of inspectionare posted on units. Each electrosurgical unit generator is assigned an ID number.

– The electrosurgical unit is properly grounded,mounted on a stand, easily cleaned and movable.

– The electrosurgical unit generator shall be keptclean and protected from spills.

– The electrosurgical unit footswitch shall be designedfor easy cleaning, shall be shock-resistant and designed to minimize unintentional activation.

– The electrosurgical unit footswitch cord shall be longenough to reach the user without stress.

– Before each use, the electrical cord, connections,plug and foot switch cord shall be inspected for damage. The unit shall be removed from service if damaged.

– Before each use, the electrosurgical unit safety features (lights, activation sound, etc.) shall be tested.

– Power settings for coagulation and/or cutting shallbe as low as possible for each procedure, confirmedorally with the surgeon before activation and determined according to manufacturer recommen-dation. Activation tones are not to be turned off or adjusted to a lower setting. (The activation tone onnewer models cannot be turned off or adjusted.)

– Before each electrosurgical unit use, the operativefield shall be inspected for alternate ground points.Personnel and/or patients may be injured, if the current does not follow the designated path. Isolatedpatient EKG lead units shall be used. The patientshall not be in contact with metal table parts.

– The patient's skin integrity shall be evaluated beforeand after electrosurgical use. Particular areas to observe are under the electrode, under EKG leads,temperature probe entry sites and positional pressure points.

– The dispersive electrode, cord and pad, and the active electrode and cord shall be retained for useduring the investigation of an adverse post-op skin reaction.

�� The Electrosurgical Ground Pad (Dispersive Electrode):

– Only disposable dispersive electrodes evaluated by the hospital Biomedical Engineer, are to be used in the Surgical Services Department.

– The dispersive electrode shall be inspected beforeeach use for wire breakage or fraying. All connec-tions shall be intact and clean.

– The dispersive electrode shall be long enough andflexible enough to be placed on the patient withoutstress on any connection.

– The dispersive electrode cord shall fasten directlyinto a labeled, stress-resistant receptacle on theelectrosurgical unit.

– The dispersive electrode pad shall be placed onthe patient, on clean dry skin over a large muscle mass, as close to the operative site as possible. Bony prominences, hairy surfaces, and scar tissueshall be avoided.

– Do not put the dispersive electrode pad over a patient's tattoo.

– Do not put the dispersive electrode pad on the patient's skin over a metal prosthesis.

Dispersive electrode and placement which restrictsblood flow shall be avoided.

– All dispersive pads shall maintain uniform body contact. Potential problems include tenting, gapingand liquids interfering with adhesion.

– Use pediatric electrosurgical ground pad accordingto weight limit.

– The pad placement area shall be charted on theIntraoperative Nursing Record and Nurses' Notes.

Electrosurgical Cautery Safety

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Policy and Procedure Forms & Tools

�� The Electrosurgical Active Electrode (Pencil):– Only electrosurgical active electrodes approved by

the hospital Biomedical Engineer are to be used inthe Surgical Services Department.

– The active electrode shall be inspected at the field for damage before each use.

– The active electrode shall fasten directly into a labeled, stress-resistant receptacle on the electrosurgical unit.

– The active electrode cord shall be long enough and flexible enough to reach the operative site and the generator without stress.

– The active electrode cord shall be free of loops, twists and metal clamps that can deviatecurrent flow.

– The active electrode and cord shall be inpervious to fluids.

– The active electrode tip shall be secure and free of charred tissue. Use a moist sponge to clean the tip.

– The active electrode will be placed in a holster at all times, when not in use.

Based upon the policy and procedure used at StonewallJackson Memorial Hospital in Lewis County, West Virginia.


Your skin is the primary barrier to infection—and just like the rest

of your body, nutrition is the secret to keeping it healthy and less

likely to break down. Remedy™, Medline’s exclusive family of

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Pressure Ulcer Prevention Policy and Procedure Forms & Tools

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

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

High Risk Diagnoses: Factors That Contribute To PressureUlcer Development

� Peripheral Vascular Disease� Myocardial Infarction� Stroke� Multiple Trauma� Musculoskeletal

disorders/Fractures� GI Bleed� Spinal Cord Injury� Paraplegia � Neurological disorders (e.g.,

Guillain Barré, multiple sclerosis)

� Those with unstable and/or chronic medical conditions (e.g., diabetes, renal disease, cancer)

� History of previous pressure ulcer

� Preterm neonates

� Age greater than 75� Existing pressure ulcer� Immobility � Those having a procedure

which immobilizes them for greater than one hour

� Bed linen � Devices (e.g., oxygen tubing,

splints, TEDs stockings)� Sedation � Sensory deficits � Nutritional deficits/Weight loss � Excessive exposure to

moisture (e.g., incontinence, excessive perspiration, wound drainage)

� Those exposed to friction and shearing


Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis

Asessement/evaluation Interventions/key points

1. Identify patients at risk for developing apressure ulcer upon admission and daily for at-risk patients or with any change in condition.

1. Determine an adult patient's risk for developing a pressure ulcer by using theBraden Risk Assessment. A patient is considered at risk if theirBraden score is: 15-18 = Mild risk 13-14 = Moderate risk 10-12 = High risk 9 or below = Very high risk 2. Advance your patient to the next risk level inthe presence of:A. Age over 75 B. Chronic illness C. Hemodynamic instability (e.g., diastolicblood pressure less than 60 mmHg). 3. Utilize the Nursing Care Plan to individualizespecific prevention interventions. 4. Initiate Pressure Ulcer Treatment Protocol atthe first sign of skin breakdown. 5. Consult WOC nurse when current plan ofcare does not meet the needs of the patient.

2. Assess specific vulnerable pressure points. A. Supine: occiput, sacrum, heels B. Sitting: ischial tuberosities, coccyx C. Side-lying position: trochanters D. Reddened areas which do not fade within30 minutes E. Dusky or cyanotic areas F. Under devices (i.e., TEDs, pneumoboots,splints, collars, tubing)

2. Inspect the skin at least every 8 hours. A. Avoid vigorous massage over bony prominences. B. Patients with dark pigmentation will demonstrate a cyanotic area, warmth or complain of pain over the bony prominence.

3. Assess skin for exposure to moisture fromintervals incontinence, wound drainage perspiration.

3. Cleanse and dry skin at routine intervals orand at the time of soiling, using a low residue soap.A. Initiate the Incontinence Protocol in the incontinent patient. B. Moisturize dry skin with lotion.


Nursing Diagnosis

4. A. Assess mobility and activity status.

B. Identify sitting status.

4. A. 1. Maintain or increase patient's level of activity, mobility and range of motion unlesscontraindicated. 2. Schedule regular and frequent turning andrepositioning at least every 2 hours (e.g., alternating supine, left lateral and right lateralpositions). 3. Individualize to the patient's needs basedon risk and level of mobility. B. For sitting position in bed (head of bedgreater than 30°), cardiac chair or wheelchair: 1. Assist/instruct patient to shift weight atleast every 15 minutes. 2. Reposition at least every 30 minutes if patient cannot independently perform pressure relief exercises every 15 minutes. 3. Consult PT/OT for assistance in seating,positioning and wheelchair cushion options.

5. Assess nutritional status. 5. Due to increased protein needs for healing,consult Nutrition Services for a nutritional assessment and plan at the earliest sign ofskin breakdown.

6. Identify factors that increase shearing, fric-tion and/or pressure. A. Shearing: Tissue layers sliding against eachother; e.g., sliding down in bed. B. Friction: Skin rubbing against other sur-faces; e.g., elbows and heels rubbing againstsheets. C. Pressure/friction: e.g., heels resting on mat-tress, devices such as oxygen tubing, cervicalcollars, casts.

6. A. 1. Keep head of bed less than 30° unlesscontraindicated. 2. Promote proper positioning, transferring andturning techniques. B. 1. Use reusable underpad, trapeze or liftsheet to lift, not drag, patient. 2. Utilize pillows or positioning devices to prevent skin surfaces from rubbing together. C. 1. The immobilized patient should have heelssuspended off bed by using pillows or heel suspension boots.2. Heel and elbow protectors are best used forreducing friction and should not be used forpressure reduction. 3. Pad devices when it is not contraindicated.

Pressure Ulcer Prevention Policy and Procedure Forms & Tools


Nursing Diagnosis

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

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

guideline. 1992.

7. Assess patient/family knowledge of pressureulcer prevention, risk factors and early treatment.

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

Forms & Tools Pressure Ulcer Prevention Policy and Procedure


Forms & Tools Policy Sample

Reprinted with permission.

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Management/Employee Checklist Forms & Tools

Checklist: Organizational Assessment Questions RegardingManagement Commitment and Employee Involvement

� Is there demonstrated organizational concern for employee emotional and physical safety and health as well as that of the patients?

� Is there a written workplace violence prevention program in your facility?

� Did front-line workers as well as management participate in developing the plan?

� Is there someone clearly responsible for the violenceprevention program to ensure that all managers, supervisors, and employees understand their obligations?

� Do those responsible have sufficient authority and resources to take all action necessary to ensure worker safety?

� Does the violence prevention program address the kinds of violent incidents that are occurring in your facility?

� Does the program provide for post-assault medicaltreatment and psychological counseling for healthcareworkers who experience or witness assaults or violence incidents?

� Is there a system to notify employees promptly about specific workplace security hazards or threats that aremade? Are employees aware of this system?

� Is there a system for employees to inform managementabout workplace security hazards or threats without fear of reprisal? Are employees aware of this system?

� Is there a system for employees to promptly report violent incidents, "near misses," threats, and verbal assaults without fear of reprisal?

� Is there tracking, trending, and regular reporting on violent incidents through the safety committee?

� Are front-line workers included as regular members and participants in the safety committee as well as violence tracking activities?

� Does the tracking and reporting capture all types of violence— fatalities, physical assaults, harassment, aggressive behavior, threats, verbal abuse, and sexual assaults?

� Does the tracking and reporting system use the latestcategories of violence so data can be compared?

� Have the high-risk locations or jobs with the greatestrisk of violence as well as the processes and proceduresthat put employees at risk been identified?

� Is there a root-cause analysis of the risk factors associated with individual violent incidents so that current response systems can be addressed and hazards can be eliminated and corrected?

� Are employees consulted about what corrective actions need to be taken for single incidents or surveyed about violence concerns in general?

� Is there follow-up of employees involved in or witnessingviolent incidents to assure that appropriate medical treatment and counseling have been provided?

� Has a process for reporting violent incidents within thefacility to the police or requesting police assistance been established?

Source: U.S. Department of Labor. Guidelines for Preventing Work-place Violence for Health Care & Social Service Workers. Available at: http://www.osha.gov/Publications/OSHA3148/osha3148.html. Ac-cessed June 19, 2008.


To: ________________________________________ Date of Incident: _______________________________________

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

________________________________________________________________________________________________

From: _______________________ Phone: _______________________ Time of Incident: ________________________

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

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

❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident ❑ Contacts with Objects or Equipment

❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other

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

Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected: ___________________________________________

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

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

Position: ___________ Member of Labor Organization? ❑ Yes ❑

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

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

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

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

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

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

Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No

OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No

Incident Response Team: ______________________________

Team Leader: __________________________________________ __________________Signature Date

Forms & Tools Incident Report

Confidential Incident Report

Source: U.S. Department ofLabor. Guidelines for PreventingWorkplace Violence for HealthCare & Social Service Workers.Available at: http://www.osha.gov/Publications/OSHA3148/osha3148.html. Accessed June 19,2008.


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