Incidents which Threaten Patient Safety Classified for Use in Teaching Operating Room Nursing

The study was conducted in an attempt to identify incidents threatening the safety of patients in the care of operating room personnel and to classify them for use in teaching safety in operating room nursing. Literature was reviewed to find concepts of safety and to aid in classification of safety hazards which are applicable to hospital patient safety. Need was shown for safe working conditions and for personnel with attitudes of safety as well as skills and knowledge. Safety included freedom from mechanical, thermal, chemical, bacteriological, and psychological injury. The descriptive method of research using the critical incident technique was used for this study. One hundred incidents were reported by 39 operating room supervisors and clinical instructors in Illinois. Besides describing the incident the participants reported the factors contributing to the incident and suggested preventive measures. Classification of the incidents was according to nature and under headings applicable to teaching. About one half pertained to the use of supplies and equipment while transportation and anesthesia accounted for over one-fourth of the incidents. Another fourth included those incidents which were related to asepsis and identification of the patient, the operative site, and medications. Very few incidents pertained to the preparation of the patient for surgery. The incidents, their contributing factors, and directives for safe operating room nursing practice were presented in tabular form. A brief interpretation was made regarding the causes of incidents as these were given by the participants. Suggestions were made for the use of the incidents for teaching safety in the operating room to students of nursing