Patient safety is one of the most important topics in healthcare today. The topic has been widely discussed in both medical and nursing literature for the past few years. The focus on patient safety became one of the most important topics in the 1990s following the study on errors in healthcare in the United States found that mistakes are much more common in healthcare operations than previously believed. Like in the case of many healthcare services, errors are likely to occur in operating rooms. The Operating Room is a medical environment that is characterized by many adverse events, making it possible for health professionals to make mistakes. It is a multifactorial cause that is associated with the complexity of procedures, interaction of people from different medical fields, and it involves working under pressure. Nurses play an important role in patient surgeries as they participate in prepping patients for surgeries while at the same time assisting in procedures. Also, nurses aid in the recovery process of the patient. At the same time, nurses assist in ensuring the safety of patients (Sevdalis, Hull & Birnbach, 2012). Therefore, this literature review focuses on nursing and patient safety in the operating room.
Definition of Patient Safety
The Institute of Medicine (IOM) defines patient safety as the prevention of any risks, threat or harm that can affect the patient. However, according to Sevdalis, Hull, and Birnbach (2012), even though patient safety is widely discussed among medical personnel and health policy makers, determining patient safety is still a complex issue, especially because safety indicators are not always available for use. They also explain that the concept of patient safety indicators is still in its development stage, making it hard to measure patient safety effectively. The effectiveness of patient safety interventions is largely due to the quality of their implementations. The checklist has become one of the most important implementation interventions in many operating rooms as it can enhance the quality of surgical outcome. Therefore, Gillespie and Marshall (2015) emphasize the need to define the concept of patient safety as well as patient safety indicators. Patient safety in an operating room can only be enhanced when healthcare professionals understand it, including its indicators.
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Historical Overview of the Role of Nurses in Operating Room
Schlich and Hasegawa (2017) conducted a systematic review of the gendered role of nurses in the operating rooms, especially between the 1870s and 1930s in the USA. The researcher conducted qualitative research by reviewing instructional literature like textbooks and scholarly articles to collect secondary data on the role of nurses in the earlier operating rooms in the USA. The research method was appropriate for the study because it allowed the collection of historical data on the topic. However, the reliability of secondary data could be a concern, because Schlich and Hasegawa could not control the quality of data collected. Traditionally, medical principles such as the unquestionable implementation of the medical order, high levels of obedience, and virtue significantly shaped the role of nurses in the operating room. Initially, nurses were required to strictly take and implement order as given by surgeons in the operating room. Surgeons became automatic leaders in the operating rooms, which resulted in the co-dependent relationship in these situations. The poor relationship between surgeons and nurses in the operating room was enhanced by the fact that almost all nurses were women while mostly all surgeons were men.
Patient safety was a concern due to the poor relationship between different medical professionals in the operating rooms. Accordingly, Schlich and Hasegawa (2017) argue that nurses were forced to use covert strategies to enhance the safety of patients while at the same time ensuring the smooth running of the surgical processes in the operating rooms even though their roles were overlooked. Patient safety is enhanced, by effective and clear communication as well as a beneficial relationship with professionals working in operating rooms.
Threats to Patient Safety
Gender
Based on the article by Schlich and Hasegawa (2017), in the second half of the 19th century, the role of nurses in the operating room was significantly redefined, and they were allowed to perform some medical functions. The argument can be said, as modern surgery evolved, nurses increasingly became authoritative, and they began to play an active role in medical productions. The new trends were influential by the slow but steady increase in the number of the males who were training as nurses. Men started entering the perioperative workforce in the 1960s, which helped in reducing the rigid hierarchical relationship that characterized the traditional operating room. At the same time, a significant number of women started pursuing surgery courses, increasing their active participation in the operating rooms. Schlich and Hasegawa (2017) maintained that the gender approach in the traditional operating rooms mainly restricted the roles of nurses to doing cleanliness during the surgical process. Nurses were not expected to meddle in the surgeon’s role despite their level of expertise. Schlich and Hasegawa (2017) concluded that nurses and surgeons should both play the role of follower and leader, and none of them should have higher privilege or capacity than one another. Creating collaborative relationships, showing professional maturity, and maintaining a high level of maturity encourages nurses to play an active role in enhancing patient safety in operating rooms. Nurses improve patient safety in operating rooms when they feel that they have equal treatment like any other medical professionals, such as surgeons.
High Demand
While gender is an important factor in the operating room, according to the study by Oliveira et al . (2015), many additional factors influence patient safety. To collect appropriate data, Oliveira et al . (2015) used qualitative research method in the form of descriptive design. They conducted a semi-structured interview to collect data from 70 nurses in public hospital. A semi-structured interview was appropriate for this study because it allowed the collection of in-depth and detail data. Nevertheless, it could have been difficult to control the level of honesty of the respondents. The study revealed some issues that nurses feel are a threat to patient safety in the operating system. Oliveira et al . (2015) found that high demand and intense workload are the main factors that threaten a patient’s safety in the operating room. Nurses are expected to do more within a concise time, which is hectic and can lead to many surgical errors. In many cases, the schedules for operations are short and time-limited, and the situation becomes worse when many patients are waiting.
Gurses et al . (2012) conducted a qualitative study to determine hazards in the cardiovascular operating room (CVOR). They used direct observation, context inquiry, and photographing to collect data from the participants. The three research approaches are strong invalidity and in-depth understanding, leading to quality data. The study revealed that the operating procedures are always timed, leading to much pressure among nurses working in the operating rooms (Gurses et al ., 2012). The pressure felt by nurses can endanger or compromise patients’ safety in the surgical room. At the same time, the pressure leads to fatigue among nurses in the operating room, making errors and unnecessary mistakes inevitable.
Fatigue
Professional tiredness and long working days in the operating room make many nurses lose concentration; leading to many medical errors (Oliveira et al ., 2015). Operating room nursing requires much concentration as nurses are required to be alert all the time and fatigue is not always an excuse. Unfortunately, the pressure to increase speed while at the same time serving many patients is a major threat to the ability of nurses to maintain constant concentration during operations. Consequently, lack of concentration makes it hard for nurses to prevent errors in the operating rooms. Oliveira et al . (2015) also found that inadequate professional training and lack of experience makes nurses lose control of circumstances in the operating room. Ignorance, lack of required knowledge and skills, and distraction, including lack of experience are some of the main factors that make nurses lose control of circumstances in the operating room. The inability to control situations causes nurses to make mistakes during surgery in operating rooms. Also, lack of proper staffing sometimes poses a threat to patient safety. Imbalance in staffing leads to unsystematic distraction, especially in the case where only a few nurses are available in the operating room against many physicians or surgeons (Oliveira et al ., 2015).
Battié et al. (2017) carried out quality research through the use of systematic literature review approach. The approach allowed the researchers to collect a large volume of secondary data on ways of addressing fatigue among nurses in the operating room. Battié et al . (2017) found that fatigue negatively affects preoperative patient care. They found that fatigue leads to inattention, reduced reaction times, and poor coordination, leading to many mistakes. Fatigue causes physical and cognitive impairment, resulting in many mistakes. Therefore, with increased demand to do more within a short period, nurses in the operating room are likely to experience fatigue, causing many mistakes that can endanger the safety of patients. In many cases, preoperative nurses or nurses working in operating rooms work longer hours, which leads to lack of adequate rest time and fatigue. Operating room nursing requires lots of resting to reduce unnecessary errors.
Exposure to Surgical Smoke
Some operation-related issues can make nurses working in operating rooms make mistakes that jeopardize the safety of patients. Fencl (2017), for instance, conducted a study to find out the effects of exposure to surgical smoke on personnel working in the operating rooms. She reviewed some articles that describe various elements of new AORN Guideline for Surgical Smoke Safety to determine how smoke-free environment can be established in the operating room. Fencl (2017) found out that being exposed to surgical smoke is not only dangerous to the patient, but also to the medical staff. It is possible for surgical smoke to reduce visibility in the operating room, which may make mistakes common in the operating room interfering with the nursing process. Surgical smoke can expose nurses to carbon monoxide gas that lowers concentration and increases dizziness. Unfortunately, many nurses in the operating room are ignorant of the effects of surgical smoke, and they are not likely to comply with the overall recommended guidelines.
Inadequate Training
The Association of Operating Room Nurses (AORN) (2018) also identified factors that can lead to medical errors while at the same time interfering with patient safety in the operating room. The major causes of medical mistakes include poor training, material resources, and staff fatigue. Van Beuzekom et al . (2012) experimented to explore patient safety in the operating room. At the same time, they used a questionnaire to collect data from the participants. The mixed research method gave the researchers the opportunity to collect detailed data from the participants. Van Beuzekom et al . (2012) found that many adverse events that occur in operating rooms are due to technique-related procedures that are implemented during operations. The variation in equipment used in operating rooms increases the chances of medical errors. Nurses in the operating rooms are likely to violate some of the patient safety rules when the equipment used is not functioning as required. Lack of training, as well as experience, are some of the major sources of medical errors in operating rooms, even though they are not always documented. According to the findings of the study by van Beuzekom et al . (2012), a high number of registered nurses in the operating room leads to better patient safety. As a result, some factors can lead to medical errors, resulting in a lack of patient safety.
Enhancing Patient Safety in the Operating Room
Pro-activeness
Oliveira et al . (2015) found that there exist some factors that enhance the safety of patients in the surgical rooms. Pro-activeness is one of the factors which helps in the prevention of operation errors before they occur. Thinking ahead is the most vital component of operating room nursing. Operating room nursing should involve imagining anything that can help with the smooth running of operations and not jeopardize the safety of patients, including taking appropriate steps aimed at preventing adverse events from occurring. Preoperative patient-centered information that is the basis of the patient’s needs and vulnerabilities is highly important in the operating room.
Teamwork
Thinking ahead and teamwork play an important role in enhancing the safety of patients in operating rooms. Kaissi, Johnson, and Kirschbaum, (2003) used qualitative research to determine the relationship between teamwork and patient safety. Specifically, they used a survey to collect data from the participants. The method is appropriate because it allowed collection of data from a large sample. By encouraging teamwork, operating room nurses are likely to develop advanced knowledge while at the same time showing a high level of performance (Kaissi, Johnson & Kirschbaum, 2003). Teamwork is one of the major elements of strengthening patient safety in the operating room. Kaissi, Johnson, and Kirschbaum (2003) also argued that operating room nursing should involve the implementation of programs that encourage and promote team functioning to improve patient safety. Teamwork is necessary for operating room nursing processes because it helps in filling the gaps and avoiding medical mistakes that can be done by individual medical personnel. Importantly, teams should be equally and adequately staffed to make them more effective.
Surgery Safety Checklists
Manrique et al. (2015) performed a quantitative study to determine patient safety in the operating room. They used cross-sectional approach to collect data from 3,033 patients to collect sociodemographic and clinical data from patients. The large sample used could help in generalizing the findings on the target population. Research by Manrique et al . (2015), on the other hand, reveals that the Surgery Safety Checklist is one of the major tools that can be used to improve the safety of patients in the operating room nursing process. The checklist is largely used in some different surgical specialties to improve the safety of patients, and nurses should adopt it when working in operating rooms. Gillespie and Marshall, (2015) also found the surgical checklist plays an important role in reducing medical errors and enhancing the safety of patients. They reviewed literature that was published from 2008 to determine how safety checklists can be implemented in operating rooms. However, they argue that the implementation of the surgical checklist should be discipline-specific, and it is highly effective when nurses are involved in its design. The success or failure of a surgical checklist is mainly influenced by socio-cultural factors, the perception of individual nurses, and availability of required resources (Gillespie & Marshall, 2015).
Özsayin and Özbayir (2016) did a qualitative survey that involved 200 operating theater members to determine the attitudes of personnel in the operating room. A survey was used to collect detailed information from the participants. Özsayin and Özbayir (2016), on the other hand, suggest that eliminating or reducing stress in the operating room is one of the best strategies that can be used to enhance patient safety. Nurses are more likely to make mistakes or medical errors when they are stressed up than when they have stable minds.
The article by Johnson and McVey (2017) that was published in the AORN Journal website also emphasized on the need to use the Surgical Safety Checklist to improve patient safety in the operating rooms. They conducted a systematic literature review to gather data on ways of improving patient safety in operating rooms. Specifically, they emphasized on the need to use the checklist that was developed by the World Health Organization (WHO) in 2009 as it can effectively help in preventing critical adverse events and mistakes. Operating room nurses should know how to use the checklist to enhance its effectiveness (Johnson & McVey, 2017). Johnson and McVey (2017) argue that improving patient safety in operating rooms requires teamwork, use of appropriate resources, and evaluation of staff member skills.
Other Factors
A study by Gurses et al . (2012) revealed that human factor engineering could be used to improve patient safety in the operating rooms. Specifically, a human factor engineering that utilizes proactive hazard analysis can substantially help in the identification of safety hazards, leading to the enhanced patient safety in the operating rooms, especially cardiovascular operating rooms (CVOR). Gurses et al . (2012) also emphasized on the need to create a safety culture in the operating rooms while at the same time complying with safety requirements and standards. Modern technologies can be used to improve the patient safety in the operating rooms.
Oliveira et al . (2015) found that positive safety culture is one of the strategies that can be used to promote patient safety in operating rooms. Nurses are most likely to adhere to patient safety rules and regulation when they are working in an environment that is characterized by positive safety culture. Nevertheless, there is a different perception among nurses on what constitutes patient safety. Blame is also a major barrier preventing error reporting in operating rooms. Error reporting is not seen as a worthwhile practice among some of the nurses and medical personnel in operating rooms.
Nurses play an important role in enhancing patient safety in operating rooms. The role of nurses in the operating room has evolved, and they are now active members of surgical procedures in many hospitals. However, operating room nurses still face some challenges in executing their roles, especially due to intense pressure, leading to fatigue and many medical errors, such as dispensing wrong medications and setting up wrong equipment during surgical procedures. At the same time, some of the physical environments of operating rooms are negative such as surgical smoke which causes nurses to make medical errors. Nevertheless, to improve the safety of patients, the operating room nursing process should involve teamwork, initiation of proactive measures aimed at reducing risks, use of a surgical checklist, and cultivation of positive safety culture. Even though some studies have been done on patient safety in the operating rooms, there is a need to conduct further studies on the specific roles of nurses in promoting the safety of patients during surgical procedures.
References
AORN. (2018). Prevention of Sentinel Events . Retrieved from https://www.aorn.org/education/staff-development/prevention-of-sentinel-events
Battié, R. N., Rall, H., Khorsand, L., & Hill, J. (2017). Addressing perioperative staff member fatigue. AORN Journal , 105(3), 285-291.
Fencl, J. L. (2017). Guideline implementation: surgical smoke safety. AORN journal , 105(5), 488-497.
Gillespie, B. M., & Marshall, A. (2015). Implementation of safety checklists in surgery: a realist synthesis of evidence. Implementation Science , 10(1), 137.
Gurses, A. P., Martinez, E. A., Bauer, L., Kim, G., Lubomski, L. H., Marsteller, J. A., ... & Thompson, D. (2012). Using human factors engineering to improve patient safety in the cardiovascular operating room. Work , 41(Supplement 1), 1801-1804.
Johnson, Q., & McVey, J. (2017). Enhancing Pediatric Perioperative Patient Safety. AORN Journal , 106(5), 434-442.
Kaissi, A., Johnson, T., & Kirschbaum, M. S. (2003). Measuring teamwork and patient safety attitudes of high-risk areas. Nursing Economics , 21(5), 211.
Manrique, B. T., Soler, L. M., Bonmati, A. N., Montesinos, M. J. L., & Roche, F. P. (2015). Patient safety in the operating room and documentary quality related to infection and hospitalization. Acta Paulista de Enfermagem , 28(4), 355-360.
Oliveira, R. M., Leitao, I. M. T. D. A., Aguiar, L. L., Oliveira, A. C. D. S., Gazos, D. M., Silva, L. M. S. D., ... & Sampaio, R. L. (2015). Evaluating the intervening factors in patient safety: focusing on hospital nursing staff. Journal of Nursing , 49(1), 104-113.
Özsayin, F. S., & Özbayir, T. (2016). Attitudes of operating theatre workers toward patient safety. International Journal of Antisepsis Disinfection Sterilization , 1(1), 1-6.
Schlich, T., & Hasegawa, A. (2017). Order and Cleanliness: The Gendered Role of Operating Room Nurses in the United States (the 1870s–1930s). Social History of Medicine , 31(1), 106-121.
Sevdalis, N., Hull, L., & Birnbach, D. J. (2012). Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. British journal of anesthesia, 109, i3-i16.
Van Beuzekom, M., Boer, F., Akerboom, S., & Hudson, P. (2012). Patient safety in the operating room: an intervention study on latent risk factors. BMC Surgery , 12(1), 10.
