Safeguard ORs Against Slip, Trip and Fall Hazards

Staff Safety

By: Laurie Wolf, PhD, CPE, ASQ-CSSBB

Published: 10/19/2022

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Address the physical environment and staff behavior to mitigate risks and remove as many obstacles as possible.


Surgery is currently dominated by two forms of turnover: The turnover of breaking down and setting up for the next case and that of OR personnel jumping ship or retiring. This combination of fast-paced scheduling and increasingly transient staff working in unfamiliar ORs run increases the likelihood a surgical team member will slip, trip or fall.

The injuries that result from these incidents involve upper and lower extremities and can range from sprains and strains to dislocations and tears. Obviously, no facility wants one of these injuries to occur, but far too many surgical leaders relegate their prevention efforts to an annual training session, which simply isn’t enough. The job of keeping your OR staff upright and injury-free is both multifactorial in nature and never-ending in practice. It requires you to account for environmental components, human aspects, room design and layout, technology and equipment as well as a variety of organizational factors to ultimately determine how to best prevent slip, trip and fall risks.

To guide your efforts, employ the following intervention hierarchy, ranked in descending order in terms of effectiveness:

1. Environmental factors

The most effective way to prevent slip and trips is to “engineer out” injury risks present in the physical OR environment. Chances are, you’ll find some improvement opportunities when you examine the following:

• Layout and design. The ideal is to design the room initially to be as safe as possible — or to renovate an existing OR to remove safety problems. Consider how equipment and cabling is set up in the OR, along with the traffic patterns of your providers. Floor outlets should be flush, but I’ve seen floor outlets that stick up several inches, creating a tripping hazard. Door thresholds are another common problem area. Even a quarter-inch of a threshold is too much; flat thresholds are safest.

• Cable/cord management. The gold standard is to convert to wireless technology and simply eliminate the cord-and-cable issues altogether. If that’s not an option, determine how you can relocate or mitigate wire hazards in provider pathways as effectively as possible. Booms are especially helpful; put as many outlets on them as you can. If possible, relocate wall outlets as appropriate, as I’ve seen cords plugged into a wall across the room and draped over too many times. Bundle cables where possible, especially those connected to anesthesia machines. Use cord covers instead of tape, which can leave a residue, to affix wires to the floor. Just be aware that those cord covers still cause a bump. Covers don’t eliminate trip hazards completely, but they are certainly safer than a loose cord in a walkway.

• Flooring. Install slip-resistant flooring if possible. However, be specific about how your staff cleans and maintains those floors. If the layer on top is the wrong consistency for that flooring, slips can result. For example, if the flooring doesn’t require wax, environmental services should be told not to apply a layer of wax to it. If they do, the floor is no longer slip-resistant.

• Fluid management. Floor-wicking absorption pads, suction devices or fluid management systems that actively remove liquid from the floor are a must for facilities that perform notoriously slippery, fluid-filled procedures such as arthroscopies.

• Lighting. Because the surgical site is illuminated so brightly in ORs, general lighting is often lowered so providers can view the monitors, resulting in shadows in darker areas. As providers age, their eyes don’t adjust to the dark as quickly, and they need more auxiliary light to reduce the contrast between the surgical field and the monitors.

• Equipment and supplies. Create unobstructed pathways around the room. Keep portable equipment such as buckets, carts, step stools and supply containers clear of high-traffic areas. The most effective approach is to make these items as visible as possible, using brightly colored supplies or flooring that contrasts against the equipment.

2. Behavioral factors

SLIP MITIGATION Fluid management systems can help keep staff safer by removing liquid from the floor as they work.

After accounting for the OR’s physical environment, consider human components — the behaviors of your staff. What are their physical and mental workload capabilities and their limitations? How do those match up with their job requirements in the OR? If there’s a mismatch or gap, close it by implementing error-proofing interventions.

• Footwear. Your providers’ shoes are a big deal. Slip-resistant shoes that tie can reduce falls. After a 10-year longitudinal study we performed at our hospitals in conjunction with the National Institute for Occupational Safety and Health, we reduced our falls by 58% in part because we looked at our providers’ footwear. Many providers like to wear foam clogs in the OR, but we found them to be a contributing factor to fall risk.

• Situational awareness. With so many people in a small OR space moving quickly and purposefully, every action a provider takes can impact someone else in the room. For instance, a busy nurse may move a stool into a walkway just for a minute, with the intention of turning back around and moving it back. But they might get distracted by something else and forget, and even if they don’t, someone could walk past during that minute and trip over it. For every little thing an OR team member does, they must instinctively consider what somebody else might do and how an action might impact them. That’s difficult to do when you’re focused on a task. An accident can happen in a split second, and people make mistakes. Providers also need to be very careful and mindful when carrying stacks of supplies, paperwork or equipment that impede their vision of the floor and their feet.

• Fatigue. While I am not aware of literature examining provider fatigue in the OR in relation to slips, trips and falls, the reasonable theory is that the longer a provider works or the more tired they are, the less mindful they may become. If there’s a bump on the floor from a cord cover, the provider might not pick their foot up as high toward the end of a long shift. During incident reviews, look not only at where falls happen but also what time of day they happen, and how far into the provider’s shift. Make sure you give your staff time off and breaks to minimize fatigue.

• Checklists and time outs. If your culture and schedule allow for it, the layout of the OR and potential fall risks should be part of the surgical checklist and the presurgical time out for each case. This gives staff a chance to bundle cords and reconsider where they’ve placed portable items in the room. Give them just a minute to think about it; it could prevent an unnecessary injury. That’s not all the forethought that can occur during this preoperative period. If they know the floor is going to get wet, what’s their plan for that? Who’s making sure pathways remain clear for walking and movement? 

3. Training and education

Beyond formal training, put effort into creative campaigns that increase awareness about slips, trips and falls that will keep the issue top of mind for whoever is on your staff year-round. For example, we once set up a hotline our employees could call if they noticed any fall risks. Every month, we collected the callers’ names from those who chose to provide them, randomly selected a winner and gave away a prize. Whether it’s a hotline, a prize program, a poster or any other great awareness idea, you need to refresh with a new one every month or two, because the novelty that spurs the awareness tends to fade quickly.

Continuous attention

OBSTACLE COURSE Portable items such as buckets, step stools and carts should be placed carefully and conscientiously out of high-traffic areas.

If a slip, trip or fall occurs at your facility, examine it with a combined reactive and proactive approach. Reactively, a systematic investigation should be conducted after every incident. Talk with the person who fell, as well as every coworker who was involved or who observed the accident. 

Do this as quickly as possible because people tend to have significantly different perspectives on what happened — perspectives that tend to change as the distance between the incident and their recollection of it grows. The proactive component involves gathering that information and identifying trends that you can address to prevent similar falls in the future.

There’s no magic way to prevent slips, trips and falls in your ORs. Instead, you and your team need to engage in constant vigilance and test new ideas to keep your surgical team upright. It’s a multifactorial process that should never end. 

For nearly 30 years, I’ve applied this approach to healthcare environments. In the process, I have prevented accidents, increased productivity, lowered injury rates and reduced worker compensation costs by implementing appropriate ergonomic interventions. Slip, trip and fall prevention efforts especially benefit from this type of system. OSM

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