 PERIOPERATIVE NURSING CARE ISSUES

Many ethical and legal issues affect the proper alignment of perioperative nursing care,
therefore, the nurse should follow the code of ethics, professional standard to nursing
care to avoid the following:

 Misinterpretation of Patient’s Identity:  Patient’s surgery may be determined

by the doctors, due to increased patient strength, patients are divided as per time
allotment by the surgical team, there are chances for misinterpretation of the
patient, wrong patient identity for wrong surgical procedure, therefore, patient’s
identification is necessary to prevent wrong identity, therefore, a wrist band bearing
name, code, age, diagnosis, surgery name, I.P number, is attached and the patient
is asked to spell the name and pronounce it before administering the sedatives or
anaesthetic drugs.
 The surgeon and perioperative nurse should personally verify the patient and
patient’s legal guardian. Wrong identity may lead to confusion and conflicts in the
perioperative team.
o The major areas where patient misidentification can occur include drug
administration, phlebotomy, blood transfusions, and surgical interventions.
The trend towards limiting working hours for clinical team members leads to
an increased number of team members caring for each patient, thereby
increasing the likelihood of hand-over and other communication problems.
o Because patient misidentification is identified as a root cause of many errors,
the Joint Commission, in the United States of America, listed improving
patient identification accuracy as the first of its National Patient Safety Goals
introduced in 2003, and this continues to be an accreditation requirement .
o While in some countries wristbands are traditionally used for identifying
hospitalized patients, missing bands or incorrect information limit the efficacy
of this system. Colour coding of wristbands facilitates rapid visual recognition
of specific issues, but the lack of a standardized coding system has lead to
errors by staff who provide care at multiple facilities.

Suggested actions:

o Emphasize the primary responsibility of health-care workers to check the

identity of patients and match the correct patients with the correct care (e.g.
laboratory results, specimens, procedures) before that care is administered.
o Encourage the use of at least two identifiers (e.g. name and date of birth) to
verify a patient’s identity upon admission or transfer to another hospital or
other care setting and prior to the administration of care. Neither of these
identifiers should be the patient’s room number.
o Standardize the approaches to patient identification among different facilities
within a health-care system. For example, use of white ID bands on which a
 standardized pattern or marker and specific information (e.g. name and date
of birth) could be written, or implementation of biometric technologies.
o Provide clear protocols for identifying patients who lack identification and for
distinguishing the identity of patients with the same name. Non-verbal
approaches for identifying comatose or confused patients should be
developed and used. Encourage patients to participate in all stages of the
process.
o Encourage the labeling of containers used for blood and other specimens in
the presence of the patient.
o Provide clear protocols for maintaining patient sample identities throughout
pre-analytical, analytical, and post-analytical processes.
o Provide clear protocols for questioning laboratory results or other test
findings when they are not consistent with the patient’s clinical history.
o Provide for repeated checking and review in order to prevent automated
multiplication of a computer entry error.

 Issues in Identifying the Accurate Surgical Site:  Improper site mark can

result in serious injury to the patient, therefore, circulatory nurse verifies the
consent, marks site “x” mark with a surgical skin marker in planned site. To avoid
the error, this verification procedure should be included in the check list of hospital
perioperative protocol.

o Methods of proper confirmation of the surgical procedure and surgical site

identification should include, but are not limited to, the following:
 A. Oral confirmation
 B. Patient identification marker
 C. Surgery schedule
 D. Patient chart (ie signed consent for surgery, history and physical
o The physician should initial the correct surgical site on the patient, if
applicable.
o It is recommended that the surgical site be “marked” to identify the intended
site of skin incision or insertion, ie trocars. Marking the site unambiguously
contributes to the safety of the patient by avoiding wrong site surgery.
o Recommendations for marking the surgical site include :
 A. No marks of any type should be made on the nonoperative site.
 B. Use clear unambiguous marks, such as “Yes” or a line marking the
proposed skin incision.
 C. The healthcare facility should establish a policy for indicating the
type of mark and method of marking to promote continuity among
the various departments of the facility.
 D. Site marking must take place with the patient conscious, alert and
oriented, and the patient indicating the surgery site.
  E. Use a permanent marker in which the mark will remain visible after
the skin prep is performed. F. The mark must be visible after the
sterile surgical drapes have been placed.

 Issues in Handling Patient’s Personal Property:  The circulating nurse is

responsible for double checking patient’s articles, such as jewellery, spectacles,
dentures, clothes, etc., and hand over after recording all the items and get signed
from patient and patient’s relatives or parents.

o Encourage patients to leave valuables at home.

 When a patient first makes arrangements for his or her hospital stay,
the admitting office and other involved parties should make it clear
that he or she should leave all valuables at home, explains Steven
Dettman, CHPA, director of security and visitor support at the Mayo
Clinic and Hospital in Scottsdale, AZ. If he or she still brings items to
the hospital, arrangements should be made for a relative or friend to
take them home.
 "These statements should be right in the hospital's admission
paperwork so the patient understands the hospital's policy up front,"
Dettman advises. Staff should also reiterate the policy verbally to
make sure the patient didn't overlook the language in the paperwork.
o Require patients to sign a liability waiver.
 If patients arrive at the hospital with valuables and are unable, for
whatever reason, to send them home, require them to sign a waiver
of liability as part of the admissions process, recommends Don
Walker, director of security at Sentara Norfolk (VA) General Hospital,
to relieve the hospital from responsibility for any lost or stolen
property, he explains.
o Offer patients a place to lock away valuables.
 If possible, make a safe or lockbox available for holding patients'
belongings. "[The safe] could be located in the admitting office or the
security office," says Linda Glasson, security manager at Obici
Hospital in Suffolk, VA.
 "Storage and lockup capabilities differ from institution to institution,"
she says, "but whatever they may be, make sure the patient
understands up front what your policy is and where [his or her] items
will be kept."
 For example, Sentara Norfolk General Hospital requires its patients to
put small valuables (e.g., watches, money, glasses, etc.) in an
envelope, sign a waiver, and keep the envelope on their person for
the duration of their stay, Walker explains.
o Large or electronic items, such as laptop computers and personal digital
assistants, are locked in a safe located in the security office.
o Use an inventory and receipt system.
 When patients request the safekeeping of their belongings, have
them place the items into a tear-resistant envelope and record the
inventory on a form that clearly displays the patient's name and date
 and time that inventory was taken. Also have space for the signatures
of two witnesses, preferably hospital staff, advises Fred Roll,
MA, CHPA-F, CPP, president of Roll Enterprises, Inc., in Morrison, CO.
 "Describe the belongings in objective terms, being careful not to write
down simply what a patient may tell you about an item," he says. For
example, a watch may be gold-colored, but not necessarily made of
actual gold. "And don't simply put down 'watch.' If it's a Seiko, write
down 'Seiko.' "
 If you put money in an envelope, note the bill and coin
denominations. These measures ensure accurate inventory control.
o When a patient is discharged, he or she turns in the receipt in exchange for
the envelope. If a patient is unable to pick up his or her items, a designated
family member or friend may do so instead.
 "When patients originally fill out the inventory form, have [them]
write down the names of one or two individuals who have their
permission to pick up items for them," suggests Walker.
o Hospitals should require all designees to show at least one form of positive
identification (e.g., a valid driver's license)-in addition to the receipt-when
retrieving belongings for a patient.
o Always make sure the patient or designee opens and empties the envelope
before leaving the security office (or wherever items are held), Roll
recommends. Have him or her double-check all of the items in the presence
of a staff member and sign out. If money is in the envelope, have the person
count it out for the staff member.
o Don't forget the emergency department (ED) and outpatients.
o Policies and procedures should make provisions for safeguarding the property
of hospital outpatients and ED visitors.
 "Patients brought to the ED are often alone and are rarely admitted to
the hospital, so we give them special green envelopes to put their
belongings in," says Walker.
 These envelopes stay in a secured location at the ED main desk. They
also include a form that serves as an inventory record for the ED staff
and a receipt for the patient.

 Issues in Observing the Patient to Protect the Patient from Accidental

Falls, Injury:  The surgical patients are transferred from the preoperative ward to
operation theatre via stretcher, while transferring the patient, there are chances for
accidental falls, injuries, slipping of the patients from starchier, if the side rails are
reversed and not locked, restraints are applied too loose or applied too tight or
safety straps are not applied correctly leading to injury in the patient. Hence, special
care should be taken in case of paediatric child and geriatric patients who are prone
and vulnerable and not able to resist the accidents and prone for falls.

 Issues Positioning of Patient in the Perioperative Phase:  The determination

about the position is done by the surgeon, assisted by the nurse, the following
measures should be taken to prevent constant pressure especially on the bony
 prominence—all the joints of legs and arms should be safely positioned, long period
of anaesthetic effect will cause neurovascular damage in the pressure sore prone
areas, for example, in case of craniotomy surgery the duration of surgery will be
more than 12 hours, therefore, adequate padding is essential to prevent such injury
due to constant position.

 Issues in Sterile Techniques:  Any break in sterile technique can result in entry

of micro-organisms via instruments that are not properly sterilized or through
surgical gloves that is hand washing. If gloving is not done as per the standards,
then entire perioperative team would be intact, if there is a doubt or break in sterile
techniques, for example, if the scrub nurse touched sterile equipment in unsterile
area, then there is a saying that implies here “when in doubt, throw it out”,
therefore, break is stopped, again the sterile technique is flourished. If the nurse
neglects the break in the sterile technique it may cause nosocomial infection causing
injury to the patient, it is like almost breaching the duty standard.

o One of the most important responsibilities of the perioperative nurse is the

ability to recognize common breaks in sterile technique. Understanding the
most common breaks in sterile technique may prevent future breaks and
promote extra vigilance.
o Common breaks in sterile technique that can increase a patient's risk of
infection often occur during sterilization, opening and setting up the sterile
field, delivering solutions to the sterile field, moving draped tables, setting up
sterile supplies, and draping.1
Sterilization
o Ensure that all sterile packages and trays are inspected prior to opening them
on a sterile field. Inspect packages for wet spots or tears. Check the
sterilization indicator in the sterile package to confirm the distinctive color
pattern ensuring the sterilization process is adequate.1,2 Any problems with
the sterile packages or trays should be reported to the central processing
department as it may indicate a larger issue.
Opening and setting up
o The process of opening and setting up requires concentration and should
never be hurried. All items introduced to the sterile field should be opened,
dispensed, and transferred by methods that maintain both sterility and
integrity.2 Unsterile individuals should not touch or reach over a sterile field,
and all items delivered to the sterile field should follow this directive. A good
rule of thumb is to hand the item directly to a scrub person to avoid
inadvertently contaminating the field.1
Delivering solutions onto the sterile field
o Delivering solutions onto the sterile field may not be easy. The scrub person
should place the labeled container near the edge of the table, while the
circulating nurse slowly pours the solution to avoid splashing. The label
should face the scrub person.2 Any remaining fluid should be discarded as
the edge of the container is considered contaminated after the contents have
been poured.
 Moving draped tables
o Only the top surface of a draped table is considered sterile.2 The circulating
nurse should always move the table by grasping below the sterile drape. If
the scrub person needs to move the table, he or she should push on the top
of the table with gloved hands and not the underside of the table.1
Leaving sterile supplies open
o Due to the risk of contamination, sterile fields should not be covered.2 This
raises the question, how long is it safe to leave the setup open? There is no
specified amount of time that a setup can remain open and unused and still
be considered sterile. The sterility of an open field is event-related, and the
field requires continuous observation.2
Draping
o Draping is very important for minimizing the chance of breaks in sterile
technique.1 The principle is simple: sterile drapes are used to establish a
sterile field to operate.2 All personnel moving in or around a sterile field
should do so in a way that maintains the sterile field without contaminating
it. Nonscrubbed personnel should maintain a distance of at least 12 in (30.5
cm) from all parts of the sterile field and sterile staff members.2
o There are many ways in which breaks in sterility may occur even with the
most conscientious perioperative practitioners. Perioperative nurses can
prevent these breaks, however when they remain vigilant of best practices.

 Issues in Responsibility and Accountability in Surgical Instruments,

Articles Count:  It is the main duty of the circulatory and scrub nurse to count the
sponges, sharp instruments, and other articles used before, during, and after
surgery. Any omission of count leads to serious injury in the patient or may lead to
patient’s death, for example, sponge left in the patient’s body and sutured, since the
count is omitted by the nurse, also the protocol should be determined to allow the
counting before, during, and after surgery, the act of omission is carelessness of
nurse and would be considered as tort doing harm to the patient.

 Issues in Use of Equipments that Needs Safe Handling, Prevention of

Injury:  Any electrical instruments used for the surgery should be thoroughly
checked for its proper functioning before use, for example, electric cautery probe
used remains hot after usage if it is kept carelessly on patient’s body it may cause
skin injury, the patient will not feel the injury since he/she is under anaesthetic
effect. Especially if any instrument is taken fresh from hot autoclave it should be
cooled in sterile water and not directly transferred to patient’s surgical site,
therefore, careful handling of sharp instrument for example, B.P handle and blade,
scissors, suturing needles, and use of electro surgical suite is important, careless
handling of instruments may lead to serious injuries in the patient, for example,
electro surgical suite is used to treat tumours, if mishandled it can cause tissue
necrosis in patient, liable for legal prosecution.
 Issues in Reporting and Monitoring the Patient’s Condition in
Perioperative Phase:  The circulatory nurse is responsible to monitor and report
patient’s vital conditions to the surgeon in time, delay or misinterpretation,
negligence or carelessness of the nurse may result in serious injury to the patient.

 Issue in Preparation of Specimens:  Surgery is done in patient as diagnostic and

therapeutic purpose, where specimens are taken for lab analysis for example, biopsy
tissue is taken appropriately labelled and sent to lab, if it is incorrectly labelled that
specimen will result in wrong interpretation of patient’s diagnosis.
o Microscopic examinations of concrete specimens can be compromised
because improper and damaging techniques are utilized in preparing the
samples. Unless great care is given to preparing specimens, it can be very
difficult to know if a simple crack was originally present or created during the
sample cutting. Extraction and preparation methods, such as coring, cutting,
drying, grinding and polishing, can create altered specimens thereby
invalidating test results and skewing research objectives.