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Priority Patient Safety Issues Identied by Perioperative Nurses
VICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN; PAULA R. GRALING, DNP, RN, CNOR; YELENA PERKHOUNKOVA, PhD
ABSTRACT
Much of the work done by perioperative nurses focuses on patient safety. Peri-operative nurses are aware that unreported near misses occur every day, and they use that knowledge to prioritize activities to protect the patient. The purpose of this study was to identify the highest priority patient safety issues reported by peri-operative RNs. We sent a link to an anonymous electronic survey to all AORN members who had e-mail addresses in AORNs member database. The survey asked respondents to identify top perioperative patient safety issues. We received 3,137 usable responses and identied the 10 highest priority safety issues, including wrong site/procedure/patient surgery, retained surgical items, medication errors, failures in instrument reprocessing, pressure injuries, specimen management errors, surgical res, perioperative hypothermia, burns from energy devices, and difcult intubation/ airway emergencies. Differences were found among practice settings. The information from this study can be used to inform the development of educational programs and the allocation of resources to enhance safe perioperative patient care. AORN J 97 (April 2013) 402-418. AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2012.06.016
Web End =http://dx.doi.org/10.1016/j http://dx.doi.org/10.1016/j.aorn.2012.06.016
Web End =.aorn.2012.06.016
Key words: medical errors, perioperative patient safety, wrong site surgery, retained surgical items, medication errors, instrument reprocessing, pressure ulcers, specimen management, surgical res, hypothermia, burns, airway emergencies.
In recent years, there have been numerous national initiatives to improve the safety and quality of patient care in the United States.1-4
In spite of this, recent research has found that 30% of hospitalized adult patients experience an adverse event,5 and some near misses go unreported. Many of these adverse events and near misses occur during perioperative care of the surgical patient. The invasiveness of the surgical procedure, the anesthesia, and the technology used, coupled with the complexities of teamwork and communication,
make the perioperative period a high-risk timefor the surgical patient. Nursing care during this window of time is provided by perioperative RNs whose priority is patient safety. These individuals are in a unique position to understand the unreported near misses that occur every day and use that knowledge to prioritize interventions and activities to protect the patient. Little is known, however, about what...