Contemporary issues in operating room care: a critical incident.
Abstract: During my training to become an Operating Department Practitioner (ODP) I experienced a situation which could have endangered a patient. I have reflected upon this incident using the Gibbs reflective cycle (see Jasper 2003) to help me analyse how the situation arose, how it could have been prevented and what I can learn from it. During the incident I was undertaking the circulating role in an orthopaedics case.

KEYWORDS Patient safety / Gibbs reflective cycle / Orthopaedics / Patient positioning
Article Type: Report
Author: Ford, Linda
Pub Date: 08/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2012 Source Volume: 22 Source Issue: 8
Accession Number: 309315277
Full Text: The incident and the resolution

A patient, who I will refer to as Mr X to maintain anonymity in line with the Health Professions Council guidelines (HPC 2008a), was about to undergo a total hip replacement on the left side. He was positioned on the operating table in a left lateral position. He had his right arm by his side on the table and his left arm on a rest that was level with his left shoulder and he had been covered from above the waist with a warming blanket. At this point the surgical team was scrubbed and ready to begin preparing and draping the patient.

I had been assisting the scrub nurse to prepare her instruments for the case. As I turned round to face the patient I noticed from my position that the patient's right arm was resting on the metal framework of the arm rest that was supporting his left (upper) arm.

I spoke to the anaesthetic ODP and pointed out the positioning of the patient's arm. The scrub nurse praised me for alerting the team to the danger and the ODP thanked me and went to get gel pads to place between the patient's arm and the framework. The ODP said that she had not worked in orthopaedics for a long time and was not used to the positioning.

When I noticed Mr X's arm on the metalwork I briefly wondered if the task of positioning the patient had not yet been completed. However, I looked around and could see the surgeon and his assistant were scrubbed and about to come to the operating table, the anaesthetic ODP was filling in forms and the warming blanket was almost obscuring the view of the patient's arm. The surgical pause had already taken place in line with the WHO checklist (NPSA 2009, WHO 2009) and local policy (LTP 2007a). I therefore concluded that everyone considered the patient to be safely positioned and that the incident had gone unnoticed except by myself.

In this particular case, most of the patient's needs with regard to positioning and preparing him for the surgery ahead had been considered and catered for. He had a sequential stocking on his right leg to protect him from deep vein thrombosis (DVT). A DVT is a blood clot that most commonly occurs in the deep veins of the leg (Hughes & Mardell 2009). He had been placed on a full length gel mattress to prevent pressure sores, and the back and abdomen supports, used to keep him in a lateral position, had been padded with extra gel pads. The anaesthetic ODP had placed a diathermy plate on the left side of his abdomen to protect against diathermy burns, in line with local trust policy (LTP 2008) and had covered the patient with a warming blanket to protect against hypothermia.

However, the patient's right arm was resting unprotected against the metal stem of the arm rest which was supporting the left arm. This created two potential risks. Firstly, the small surface area of the framework was creating pressure on an area of the patient's arm which could lead to a pressure sore or nerve damage developing during the procedure. Secondly, the contact with the metalwork could lead to burns during the use of diathermy.

As soon as I noticed the patient was inadequately positioned I brought it to the attention of the appropriate member of staff (the ODP). It was swiftly dealt with by the ODP padding the arm rest, which removed the risks of pressure sores, nerve damage and diathermy burns, rectifying the situation satisfactorily.

I later reflected on what could have caused the incident to occur.


The anaesthetic ODP was from a different speciality. She was very experienced in her area but was not used to positioning a patient for this particular procedure. Perhaps she was relying on the surgeons to have the knowledge to position their patient safely.

The surgeons perform this operation on a regular basis and usually take over much of the placing of positioning equipment. It is therefore surprising that they did not place the appropriate padding between Mr X's arm and the bracket, and also understandable that the ODP could have assumed that the surgeons had the positioning under control. From their point of view however, the surgeon may expect the ODP to pick up on positioning requirements.

Positioning takes place quickly, and as in this case is often a rushed process. I think this contributed to the lack of padding going unnoticed. The warming blanket was placed on the patient to prevent perioperative hypothermia, as discussed by Rothrock (2007). Mr X was now covered above the operating site and the view of his arm was obscured from most of the surgical team. This again would lead to the situation going unnoticed.

I was positioned at the edge of the sterile field behind the scrub nurse's trolley, in line with the foot of the operating table. From this angle I was able to see under the warming blanket to the patient. I had been passing equipment and materials to the scrub nurse. I had completed this task and so was probably the only person facing Mr X at that moment who was not otherwise occupied. It is very fortunate that I was able to look at the patient at that time and pick up on the absence of padding.

I could see the patient's right forearm resting on the metal bracket of the arm rest. The narrow surface area of the bracket was pressing on a small part of the patient's arm creating an area of pressure. This pressure put him at risk of peripheral nerve damage, particularly of his radial nerve. Pressure relieving devices are important to protect the patient from nerve damage or pressure sores (Phillips 2007). By spreading body weight over as large an area as possible, the risk of occluding blood vessels and causing subsequent tissue death, can be reduced (Waterlow 1996). Contractor and Hardman (2006) discuss the occurrence of peripheral nerve damage during anaesthesia and attribute its commonest cause to poor patient positioning. They point out that the mechanism of this type of injury is usually compression of the vasa vasorum, leading to ischemia. Vasa vasorum are described by Marieb (2010) as the 'vessels of the vessels' which facilitate nourishment of the external tissues of the blood vessel walls. Contractor and Hardman (2006) also suggest that whole limb ischemia can occur which may lead to compartment syndrome.

The risk of pressure sores

The pressure on Mr X's arm put him at risk of developing a pressure sore. The Waterlow score (Waterlow 2005) is a tool that assesses the risk of obtaining pressure sores. It gives a score for build, weight and height, skin type, sex and age, neurological deficit, nutritional status, continence and mobility. These scores are added together. A score of 10+ indicates risk. 15+ indicates high risk and 20+ indicates very high risk. Mr X was considered at risk.

Pressure sores may develop when there is a sustained occlusion of the vascular network. Uninterrupted pressure prevents circulation of blood and lymph and causes deficiency of nutrition to tissues and the build up of waste products. Blood vessels collapse and clots or thromboses (Blackwell Science 1998) occur if the pressure is not relieved. Prolonged compression causes tissue damage which can then continue to occur even after release of the pressure. Pressure damage may not be apparent until around 72 hours after surgery (Beckett 2010). This type of injury can be serious and long term. Pressure sores can be deep, may be slow to heal and can be a route of infection (Ousey 2005).

The risk from diathermy

The contact of Mr X's arm to the metal bracket posed the further hazard of potential burns from the use of diathermy equipment.

A diathermy machine utilises the effects of electrical current to cut tissue and prevent bleeding. High frequency current passes from the diathermy machine through the body via an instrument, an active electrode, which has a metal tip and causes cutting and/or coagulation by burning the local tissue at the point where current density is high. Mono-polar diathermy involves the current travelling through the surgical instrument where the current density is high, travelling through the patient's body and exiting through a diathermy plate which is stuck to the patient. At this exit point the current density is low and current travels back to the diathermy machine via a lead attached to the plate. If the patient comes into contact with metal, such as on the operating table, the current can travel back to earth at this point and can cause a burn to the patient at the site where current leaves the body (Aitkenhead et al 2007).

There were clearly several serious potential risks to the patient's safety occurring from one small error.

Considering the options

I contemplated how the sharing of responsibility can be a benefit or a hindrance. If the surgeons had taken the responsibility of positioning the patient and checking his safety before leaving the table to scrub they may have been aware that an error had been made. Similarly if the ODP was ultimately responsible for checking the finished positioning she may have been aware that an error had occurred. The fact that no-one noticed suggests that it is likely that everyone walked away from the table without checking as each thought the matter was in hand with someone else.

Alternatively, it could be suggested that the more people there are involved in the task the more people there are to assess whether or not the task has been completed safely. However, this is more likely to be the case if a moment is taken to confer and agree that the task is complete.

All members of the team including circulating and support staff are of course free to make observations, but as they are less likely to be involved in the positioning they are less likely to be aware. My role during this incident required my attention to be with the scrub nurse rather than with the patient during the positioning process. It was therefore by chance that I happened to move my attention to the patient in time to be aware of the positioning error.

My approach was to notify the ODP. It is possible that some professionals would not have taken well to having an error pointed out to them by a student. However, the ODP in this particular incident reacted very well. She did not appear to take offence at all. She thanked me and took responsibility for a mistake she appeared to consider was hers.

Human error and responsibility

It is an unfortunate consequence of being human that mistakes sometimes occur. It is impossible to eliminate all mistakes. Team work helps to reduce error with everyone working towards the common goal of achieving patient safety. As soon as a patient has been anaesthetised they become powerless and extremely vulnerable and need others to act as advocates by speaking and acting on their behalf (Teasdale 1998). If everyone acts individually as the patient's advocate, as described by Beyea (2005), taking on the responsibility of looking out for their well-being at all times, then hopefully these mistakes will be noticed and picked up in time to prevent a negative outcome.

As professional healthcare workers, staff are only allowed to practice within the boundaries of their registration with the Health Professions Council. ODPs are required to act in the best interests of service users at all times. They must recognise that they are personally responsible for and be able to justify their own actions and decisions (HPC 2008b). We are all responsible and accountable for the patient's well-being.

In this instance it has been demonstrated that professionals working as a team develop a routine relating to their practice. I would suggest that changing members of the team can lead to oversights being made as roles may not be clearly defined.

The anaesthetic ODP had been placed in a speciality that she did not usually work in. However, although the ODP would have trained in orthopaedics, not working in that speciality for several years can lead to a lapse of skills and a reduction of competency. This can lead to error. Working regularly in one area brings with it the opportunity to become an expert in that field. Benner (2000) describes five levels of taxonomy ranging from novice to expert. Practitioners who achieve the expert level may not retain it without practice.

It could be suggested that professionals should not move out of their specialities thus ensuring that appropriately experienced staff are caring for the patients. Conversely it could be suggested that moving staff around between specialities on a regular basis ensures that skills are retained to a level that ensures patient safety.

It may be that the surgeons not noticing the poor positioning could be due to over confidence in their field leading to complacency. The fast pace at which the list was being conducted would also be a likely contributing factor.

The checklist

There are many checks and policies in place to safeguard the patient. The team stop prior to surgery for the surgical pause in line with the WHO checklist (NPSA 2009). The detail on each patient's wrist band is checked against the consent form (LTP 2007a), and the surgical site is checked to be correctly marked in line with local policy (LTP 2007b) to prevent wrong site surgery. The anaesthetic ODP informs the team of any known allergies and metalwork from prior operations.

This could be a good time to pause and assess the positioning of the patient. I think it would further protect the patient if the whole team was involved in viewing the patient and verbally agreeing adequate care at this point. There are already care plans in use with tick boxes to ensure various other checks have taken place. I think the addition of a box to say that the whole team was happy that the patient was positioned safely, would be beneficial.

Perhaps this is a subject which could be broached with the local trust's risk assessment team. Audits are conducted in order to assess levels of risk and the results highlight safety issues that need to be addressed. From this information risk management strategies can be devised to reduce or eliminate risk (NPSA 2011). The clinical governance system ensures that NHS organisations are accountable for continual improvement of their standards of care. Clinical audits are measurement and quality improvement tools which are used with the aim of improving patient care through review (DH 2010).


Having now become aware that the described situation can occur, it is my intention to always make a visual check of the patient prior to the draping taking place. This will ensure that I am personally satisfied in this regard and confident that I am acting in the best interests of the patient and taking responsibility for their care.


Aitknehead A, Smith G, Rowbotham D 2007 Textbook of Anaesthesia 5th ed London, Elsevier

Beckett A 2010 Are we doing enough to prevent patient injury caused by positioning for surgery Journal of Perioperative Practice 20 (1) 26-29

Benner P 2000 From novice to expert: Excellence and power in clinical nursing practice New Jersey, Prentice-Hall

Beyea S 2005 Patient advocacy: nurses keeping patients safe AORN Journal 81 (5) 1046-1047

Blackwell Science 1998 Blackwell's Dictionary of Nursing Edinburgh, Blackwell Science Ltd

Contractor S, Hardman J 2006 Injury during anaesthesia Continuing Education in Anaesthesia, Critical Care and Pain 6 (2) 67-70 Available from: [Accessed May 2012]

Department of Health 2010 Clinical governance Available from: [Accessed May 2012]

Health Professions Council 2008a Confidentiality: Guidance for registrants [Accessed May 2012]

Health Professions Council 2008b Standards of conduct, performance and ethics Available from: [Accessed May 2012]

Hughes S, Mardell A 2009 Oxford handbook of perioperative practice Oxford, Oxford University Press

Jasper M 2003 Beginning reflective practice Cheltenham, Nelson Thornes Ltd

Local Trust Policy 2007a Policy for checking patient's identity prior to operative procedures in main and day stay theatres

Local Trust Policy 2007b Policy for correct site surgery

Local Trust Policy 2008 Policy for the application and use of diathermy

Marieb E 2010 Human anatomy and physiology 8th ed London, Pearson Education

National Patient Safety Agency 2009 WHO surgical checklist Available from: [Accessed May 2012]

National Patient Safety Agency 2011 Risk matrix for risk managers Available from: [Accessed May 2012]

Ousey K 2005 Pressure area care: Essential clinical skills for nurses Oxford, Wiley-Blackwell

Phillips N 2007 Barry and Kohn's operating technique 11th ed St Louis USA, Mosby

Rothrock J 2007 Alexander's care of the patient in surgery St Louis USA, Mosby

Teasdale K 1998 Advocacy in healthcare Oxford, Blackwell Science Ltd

Waterlow J 1996 Operating table: The root cause of many pressure sores British Journal of Theatre Nursing 6 (7) 19-21

Waterlow J 2005 Waterlow score Available from: [Accessed May 2012]

World Health Organisation 2009 Surgical safety checklist Available from: [Accessed May 2012]

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by Linda Ford

Correspondence address: c/o The Association for Perioperative Practice, 42 Freemans Way, Harrogate, HG3 1DH. Email:

About the author

Linda Ford


Operating Department Practitioner, Essex

No competing interests declared

Provenance and Peer review: Unsolicited contribution; Peer reviewed, Accepted for publication April 2012.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.