Can You Pass This Patient and Staff Safety Quiz?

Test your knowledge of best practices and events that shape and highlight the delivery of safe surgical care.

Perioperative teams keep patient and staff safety top of mind at all times, even during days with high volumes of cases that could pose distractions to providing safe care – and protecting each other. We hope these questions provide a reminder of how surgical teams from around the country are up to speed on the latest ways to protect patients from harm. Let’s get started!

1. After a team of ICU nurses reported and investigated an excess number of false occlusion alarms from an IV pump, what was the final outcome?

• a. No changes.
• b. The health system they worked for bought a different brand of pump.
• c. A national recall to fix a software glitch.
• d. None of the above.
• Reveal

  • Answer: c
    The team of adult critical care nurses in the ICU unit at Beth Israel Deaconess Medical Center noticed that medication pumps were emitting a high amount of false occlusion alarms, which was interrupting the delivery of crucial medication.
    
    They worked with the manufacturer and learned that a software upgrade caused the problem. Realizing that patients across the country were at risk, a nationwide recall of the pumps began in an attempt to avert potentially serious patient harm. The FDA recognized the team’s achievements, as did the DAISY Foundation, which gave the team its Extraordinary Nurses in Patient Safety Award.
    
    “This is a demonstration of how the staff is passionate about accountability for practice, and most importantly, how they use this passion to advocate for change,” says Pat Folcarelli, PhD, MA, RN, Chief Nursing Officer, Beth Israel Deaconess Medical Center.
    
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2. How many states have laws that mandate the evacuation of surgical smoke from operating rooms?

• a. 18 down, 32 to go.
• b. 43 down, seven to go.
• c. Eight down, 42 to go.
• d. All states now have such laws.
• e. Bills have been introduced in a handful of states but haven’t passed anywhere yet.
• Reveal

  • Answer: a
    Eighteen states have surgical smoke evacuation mandate laws. Perioperative professionals in West Virginia, Virginia and Minnesota worked tirelessly with state lawmakers to get laws passed in 2024. They joined these 15 states who passed such laws, starting in 2019: Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island and Washington.
    
    The Association of periOperative Registered Nurses (AORN) played key roles in many of these laws getting passed. Jennifer Pennock, AORN’s associate director of government affairs, says there is promise that Massachusetts, North Carolina and Pennsylvania could join the list this year.
    
    Some facilities are going smoke-free before its state orders them to do so. One is Jamestown Regional Medical Center in North Dakota. “While the research on the risks of surgical smoke is still evolving, we want to do everything in our power to safeguard those in our care,” said JRMC President and CEO Mike Delfs, MBA, when the policy was announced to the public. “Going smoke-free aligns with our dedication to leading with science and pursuing the highest standards of clinical excellence.”
    
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3. What percentage of communication failures between providers, patients and members of patients’ support networks take place during handoffs, including the discharge process?

• a. 9%
• b. 26%
• c. 50%
• d. 67%
• e. 91%
• Reveal

  • Answer: d
    Communication failures is one of the most common causes of medical errors, according to the recently released Top 10 Patient Safety Concerns 2025 by ECRI, an international medical safety nonprofit. “Inadequate communication and coordination during discharge,” is ninth on the list.
    
    Poorly managed care transitions can lead to adverse events, poorer outcomes and increased treatment costs. Part of why these transitions go bad is because the information discussed often comes from discharge summaries, which frequently lack nuance and sometimes use abbreviations that can be misinterpreted.
    
    The handoff from provider to the member of their support network can be as important as those from provider to provider, says the ECRI report.
    
    “Effective communication and coordination between healthcare professionals and patients, their families, and caregivers are also crucial for ensuring a safe patient discharge,” states the report. “Engaging patients and families in the discharge planning process has been shown to result in reduced hospital readmissions.”
    
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4. Speaking of the ECRI list, the No. 1 patient safety concern in the 2025 report is “medical gaslighting.” Which of the following are examples of this phenomenon?

• a. Dismissing or refusing to discuss symptoms or medication concerns.
• b. Minimizing the severity of symptoms, especially pain.
• c. Ignoring or interrupting patients.
• d. Misattributing symptoms to mental illness, weight, age or other attributes.
• e. Refusing to order follow-up tests.
• f. Patient-blaming or condescendingly suggesting the patient is exaggerating.
• g. All of the above.
• Reveal

  • Answer: g
    “Medical gaslighting is not driven by an intentional desire to manipulate patients, and clinicians may not be aware they are exhibiting gaslighting behavior,” states the report. “Dismissing patient concerns can also arise from a clinician’s preconceived ideas about specific symptoms, misunderstandings of certain medical conditions, unconscious biases, challenges regarding causes for nonspecific complaints or cognitive biases in clinical decision-making.”
    
    As solutions, ERCI recommends setting patient trust as a top organizational priority, as well as holding open conversations about the impact of medical gaslighting behaviors.
    
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5. Which is the best way to keep unintended retained surgical items (URSIs) a Never Event?

• a. Always rely on the tried-and-true manual counts of your team.
• b. Replace those manual counts with a technology alternative.
• c. Use a technology as an adjunct to manual counts.
• d. Stay the course and wait for advances in AI and robotics to arrive.
• Reveal

  • Answer: c
    Always use a high-tech product to help to avoid URSIs, but always in addition to, not instead of, manual counts, says Jason Goodwin, RN, MSN, MPH, CNOR, a perioperative nurse lead and quality and safety expert.
    
    “Barcode scanning and radio frequency identification (RFID) wands are similar to radiology studies in that they serve as an underlying safety net. But they’re not intended to ever be used as the primary source of verification,” says Mr. Goodwin. “They are the backstop for processes that can be easily disrupted without deliberate management and tracking.”
    
    Mr. Goodwin believes future advances will help in reducing URSIs.
    
    “As soon as we have artificial intelligence and robots monitoring, managing and designing our systems, we can improve drastically,” he says. “Humans can operate at a pretty high level. But AI and robotics can help perfect our human responses.”
    
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6. Which of the following isn’t a core tenet of a sound sharps safety prevention program?

• a. Establish an organizational sharps safety plan.
• b. Select team-approved safety-engineered devices and PPE.
• c. Educate staff with evidence and personal stories.
• d. Improve your sharps injury reporting.
• e. Start a committee to investigate the issue before authoring an action plan.
• Reveal

  • Answer: e
    Sharps safety is a problem that’s never solved, despite years of increased awareness and prevention issues about the issue.
    
    Sharps injuries statistics from 2023 show a 16% increase from 10 years earlier. And ORs continue to be a top location where needlestick and other sharp object injuries occur. Nearly 43% of these injuries took place in operating rooms in 2023, according to surveillance data from the International Safety Center’s EPINet.
    
    “The highest percentages of injuries and exposures occur in the operating room and PACU, most often from devices being used in a multi-step procedure like passing,” explains Amber Hogan Mitchell, DrPH, MPH, president and executive director of the International Safety Center. “These same risks transfer to outpatient surgery centers, yet usually without full support of a health and safety or infection prevention team.”
    
    Beyond the OR, indirect exposure across the perioperative setting can be just as dangerous. Sterile processing professionals and environmental services staff are at risk for exposure when a sharp is not properly packaged for reprocessing or disposed of correctly, notes Dr. Mitchell. OSM
    
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