Can You Pass This Patient Safety Quiz?

Staff Training and Education Patient Safety

By: Joe Paone | Senior Editor

Published: 8/10/2022

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Test your knowledge of best practices in the delivery of safe surgical care.


Patient safety should be top of mind at all times, even when high-volume days and high-pressure situations threaten to distract the clinical team from taking the necessary steps to reduce the risk factors that can lead to adverse events. That demands creating a culture of transparency and making sure you're up to speed on the latest ways to protect patients from harm. We hope this quiz helps with those efforts, so sharpen your pencils and let's get started!

1. Monitoring patients for hypothermia prior to and during the preoperative period is just as important as intraoperative body temperature monitoring.

  • a. True
  • b. False
  • Reveal

    • Answer: a
      The overall clinical significance of preoperative warming is not yet fully understood or appreciated at many facilities, according to Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, director of evidence-based perioperative practice at the Association of periOperative Registered Nurses (AORN). "Seeing the big picture is important when addressing patient hypothermia and should include both subjective and objective data," explains Dr. Spruce. As such, she says, preoperative assessments should include not only checking a patient's temperature but also asking them if they feel cold. Explaining to patients the importance of hypothermia prevention is an important aspect of patient and family education.
      Current AORN guidelines instruct providers to measure and monitor the patient's temperature during all phases of perioperative care. Dr. Spruce notes that longstanding recommendations from the U.K.'s National Institute for Health and Care Excellence (NICE) address prewarming even beyond the facility. NICE advises that patients, along with their families and caregivers, be informed that staying warm before surgery lowers the risk of postoperative complications and that the surgical environment might be colder than their own home.
      "From the provider's perspective, it's important that patients are not coming into the perioperative suite cold because it can take a while to get their temperature back up to normal," says Dr. Spruce. "Hypothermia results from direct heat loss in a cool operating room environment and impaired thermoregulation that is associated with anesthesia. It's important, then, that the patient's body isn't using its metabolic resources such as shivering to compensate for a low body temperature preoperatively."
      Close

2. After an unexpected event during surgery, a patient is wheeled to the PACU before an RFID or barcode system could be used to count surgical items used during the procedure. In this case, the adjunct technology should be used once the patient is stabilized.

  • a. true
  • b. false
  • c. follow your facility's policy and procedure for use of the device
  • Reveal

    • Answer: b
      Once the patient is in the PACU, the opportunity to confirm that there are no retained surgical soft goods has passed. "At that point, anything left inside the patient would be considered a retained surgical item," says Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, senior perioperative practice specialist at AORN. "If there's something left in the wound and you've already closed — applied the final stitch, staple or surgical glue — then that is a retained surgical item. Making sure you get everything back before closing is crucial."
      Patients with a retained sponge require a removal procedure that is not reimbursed. That can lead to patient dissatisfaction, potential implications to the reputation of the facility and possible second victim phenomenon for involved personnel, notes Dr. Cahn.
      Facilities should strictly follow the manufacturer's instructions for use when using adjunct technology. "Clarify in your policy and procedure when these devices will be used during your manual counting processes," says Dr. Cahn. While AORN recommends that counting processes and reconciling of counting discrepancies should be completed before wound closure, individual facility policies may vary.
      Adding explicit instructions to your policies and procedures to ensure the use of the adjunct technology at the correct stage of the surgery is especially important because the tech is employed toward the very end of procedures. "Many things are occurring simultaneously at that time, which can cause distractions and interruptions," says Dr. Cahn. "Clarifying standardized procedures for use of this technology during the counting process can empower staff to ensure that adequate time is dedicated to correct use of the device as part of patient safety measures."
      Close

3. Smoke evacuation is purely a staff safety issue, as patients aren't exposed long enough to surgical smoke to experience any negative effects.

  • a. true
  • b. false
  • Reveal

    • Answer: b
      The health hazards of surgical smoke exposure for OR staff have been well-documented and described, but what about the patient? "Surgical smoke contains harmful chemicals and lung-damaging particles, and everyone who is in the operating room — even our patients — could be exposed to these hazards," says Emily Jones, MSN, RN, CNOR, NPD-BC, perioperative practice specialist at AORN. "Research shows that the concentration of fine particles accumulates to unhealthy levels within seconds after smoke production starts, and that exposure to even a small amount of plume could be harmful. That's why smoke should be evacuated and filtered in all surgical settings. It's a simple way for perioperative staff members to protect one another and the patients in our care."
      AORN's Surgical Smoke Safety Guideline points to the patient experience aspect of smoke evacuation as an important consideration. The guideline cites a single-blinded randomized controlled trial of 160 adult patients undergoing wide-awake outpatient Mohs micrographic surgery that compared patient experiences when smoke evacuation was used for some procedures and not for others. "As you can imagine, patients noticed and were more bothered by the smell of surgical smoke when smoke evacuation was not used," says Ms. Jones.
      In a smaller comparative pilot study cited in the guideline, 36 patients were surveyed about their perception of electrosurgery smoke after undergoing Mohs surgery where smoke evacuation was used during closure, but not during staging. All patients reported perceiving a burning odor when smoke evacuation was not employed during staging, compared to 40% of patients who perceived an odor during closure when the smoke evacuator was on. Two-thirds of the patients reported that the odor during surgery was unpleasant, while just one-sixth reported an unpleasant odor during closure when the evacuator was operating.
      "Surgical smoke evacuation can also improve patient satisfaction," says Ms. Jones. "A patient who is awake during surgery, such as with local-only anesthesia procedures, will likely have a better surgical experience if they don't smell the bothersome odor of surgical smoke."
      Close

THE RIGHT STUFF A time out for regional block placements in preoperative areas is crucial to prevent wrong-side and wrong-site errors.  |  Pamela Bevelhymer

4. In a 2021 study conducted by the University of Chicago and Embry-Riddle Aeronautical University, 2,006 U.S. adults were surveyed about a hypothetical surgery. What percent were unwilling to have lifesaving surgery without universal COVID-19 vaccination of hospital staff?

  • a. 9%
  • b. 17%
  • c. 24%
  • d. 35%
  • e. 42%
  • Reveal

    • Answer: c
      This survey indicates that about a quarter of patients wouldn't have lifesaving surgery without assurances that all facility staff were vaccinated. Now imagine how some patients must feel about presenting for less urgent elective surgeries. The American Society of Anesthesiologists (ASA), which publicized the results in the June 2022 edition of the journal Vaccine, says vaccinated survey participants were more willing to have a surgical procedure than the unvaccinated. ASA also notes that the 24% "unwilling" figure decreased to 15% with universal vaccination of staff, and that Americans are more likely to have surgery during a pandemic if the surgery is outpatient. "Our study reveals that people have real fears about acquiring an infectious disease in the hospital if they need surgery during a global pandemic," says study co-author Anna Clebone Ruskin, MD, an associate professor of anesthesia and critical care at the University of Chicago. "The findings are not only relevant to COVID-19, but to future infectious disease pandemics."
      Close

5. According to a recent literature review, this type of "wrong" surgical error could occur as frequently as 7.5 times per 10,000 procedures.

  • a. wrong extremity
  • b. wrong patient
  • c. wrong procedure
  • d. wrong block placement
  • Reveal

    • Answer: d
      The authors of the literature review identified a multitude of factors that contribute to inaccurate placement of regional blocks, including scheduling changes, poor communication, incomplete documentation, patient position change, physician distraction and failure to perform a time out. It's that last one — failure to perform a time out — that can potentially address the other factors.
      "We added a time out to AORN's Guideline for Team Communication because we identified based on the literature that this is an area where wrong site blocks have occurred," says Dr. Spruce, who says the incorrect placement of regional blocks by anesthesia providers is an issue that often flies under the radar at many facilities. She recommends conducting a regional block time out in a pre-op bay, an area where time outs aren't typically performed but should be considered by the care team as a standard practice. Another reason why a pre-op block time out is now part of AORN's Guideline for Team Communication is that errors in block placement are not solely the responsibility of anesthesia providers. "The nurses also play a big role," says Dr. Spruce. "It's an interdisciplinary process that might involve the circulating nurse, pre-op nurse and anesthesia provider, and all should be aware that a time out is necessary before the procedure begins. At a minimum, the team must confirm the correct patient, site and procedure to be performed just as they would in the OR."
      Close

6. An anesthesia provider is on their way to work a routine short procedure, and the nurse wants to be efficient and proactive. How far in advance should the nurse pull anesthetic drugs in anticipation of the anesthesia provider's arrival?

  • a. when they receive a verbal order
  • b. 15 minutes before the procedure
  • c. when the anesthesia provider is physically in the procedure room
  • d. when the anesthesia provider messages that they'll be there in 10 minutes
  • Reveal

    • Answer: a
      Nurses should always have an order before removing any medication from a secure storage location, says Susan Paparella, MSN, RN, vice president of services at the Institute for Safe Medication Practices. In a busy surgical facility, that might seem a bit rigid, but there are very good reasons not to jump ahead of things in this case.
      "When there's a planned procedure, nurses may, because of time constraints, try to anticipate what medication is going to be used," says Ms. Paparella. "It's just part of what nurses do every day — trying to be efficient to stay on time. The intent is to be ready for the anesthesia provider, but nurses don't realize the risk they're creating for themselves and for their patients when they remove medications from storage without an actual order."
      These risks involve unsupervised access to an unauthorized medication and possible administration of a medication by the wrong route, such as an epidural infusion confused with an antibiotic infusion, which can sometimes look alike. "A simple misstep can result in a critical adverse event for the patient," says Ms. Paparella. "It also can result in serious outcomes for the nurse, especially if it's a controlled substance and the nurse removed it without an order. This action would be outside of most organizational policies and procedures as well as outside the nurse's scope of practice." To limit this activity, some organizations do not allow nurses to remove controlled substances for other providers to administer, she says.
      Close

COZY AND SAFE As a general rule, if a patient says they feel cold, give them a warm blanket — even if their temperature readings suggest they don’t need one.  |  Parkland Hospital

7. The Malignant Hyperthermia Association of the U.S. (MHAUS) says _____ providers should prepare the lifesaving dantrolene medication for administration during an MH event.

  • a. 1
  • b. 2
  • c. 3
  • d. 4
  • Reveal

    • Answer: c
      Calculating, mixing and administering dantrolene is a three-person job, says Jacqueline Sumanis, DNAP, CRNA, assistant director of nurse anesthesia services at Memorial Sloan Kettering Cancer Center in New York City and a member of the board with MHAUS. "It's not a standardized recommendation, but what we've found at MHAUS — and what I find typically in simulations when I have an opportunity to watch people do it — is that three staff members is the number that works best," she says.
      While dantrolene preparation is not a complicated process, it includes many exacting steps that must be performed as quickly as possible under sudden stress. "It's labor-intensive, time-consuming and a really big challenge physically," explains Dr. Sumanis. After calculating how many vials of the medication are needed based on the patient's weight – an average-sized patient can require eight vials of dantrolene — providers must place the drug and 60 ccs of sterile water in each vial, shake each vial and pull and push the syringe. "Staff members are always surprised by how long it takes," she says.
      Dr. Sumanis says that by having three providers simultaneously prepare the necessary dantrolene, each individual provider is less physically taxed and better able to concentrate on the task at hand. She emphasizes that either physical or digital checklists that include calculations for the dosages should be readily available and visible in every OR, so the trio of providers can quickly spring into action.
      Close

8. Of the 288,882 patient safety event reports submitted by Pennsylvania healthcare facilities in 2021, what percentage were from ASCs?

  • a. 3.1%
  • b. 7.9%
  • c. 12.0%
  • c. 14.6%
  • c. 21.7%
  • Reveal

    • Answer: a
      Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm, making the Pennsylvania Patient Safety Reporting System the largest repository of patient safety data in the U.S. and one of the world's largest. While 3.1% sounds like ASCs, which Pennsylvania calls ambulatory surgical facilities (ASFs), are much safer than hospitals, there's more behind that number than initially meets the eye.
      "The proportion of patient safety event reports submitted by hospitals versus ASFs is relatively consistent with what we have seen in previous years," says Rebecca Jones, MBA, RN, director of data science and research at the Pennsylvania Patient Safety Authority. "The nature and scope of care provided in an ASF is different than what's provided in an acute care hospital, which has a significant impact on the number and types of patient safety risks in each setting. In addition, a higher number of event reports can signal an open and positive safety culture."
      The reporting rate from ASFs in the first half of 2021 was 8.6 reports per 1,000 surgical encounters. Ms. Jones says the most common patient safety events reported were errors related to procedure, treatment or test (35.8%); complication of procedure, treatment or test (30.3%); and other/miscellaneous (24.5%). The remainder were skin integrity (2.6%); fall (2.4%); equipment/supplies/devices (1.7%); medication error (1.5%); adverse drug reaction (1.1%); and patient self-harm (0.1%). OSM
      Close

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