Saving skin; labeling medications; separating procedures; opening supplies; bare arms; safety straps

AORN Journal,  Jan, 2001  by Ramona L. Conner

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Question: Some surgeons at our facility wish to save fresh skin tissue taken but not used during skin graft procedures in the event the graft does not take. We have clone this in the past by placing the skin in a sterile specimen container filled with saline; however, we do not have a written policy regarding this practice and are looking for guidance.

Answer: The American Association of Tissue Banks standards should be followed.(1) The skin should be placed in a sterile storage container using aseptic technique and stored in low-temperature storage under aseptic conditions. The container should be labeled with the patient's name and other identifiers, contents, and expiration date. Any solutions, such as antibiotic or isotonic solution, should be included on the label.

If the skin is to be transplanted within 14 days, it can be stored in a temperature-controlled refrigerator. The skin temperature must be maintained at 1 [degrees] C to 10 [degrees] C (33.8 [degrees] F to 50 [degrees] F). The refrigerator should be equipped with an electronic monitor and an alarm to alert staff members when temperatures are outside acceptable limits. Access to the refrigerator should be limited to authorized personnel. Staff members should monitor access daily, maintain a log to document refrigerator temperature, and perform annual calibration checks.(2)

Skin also can be frozen and stored for up to five years. The skin must be frozen to at least -40 [degrees] C (-40 [degrees] F).(3) Freezing must be accomplished slowly and at a steady rate to maintain the structural integrity of the skin. This procedure is impractical to perform in typical OR settings because of the complexity of the technique and the necessary equipment; frozen storage usually is performed in a medical laboratory setting.

Question: My manager wants us to label all medications on the sterile field, even if there is only one. Does AORN recommend labeling all medications on the sterile field?

Answer: All medications on the sterile field should be labeled properly, even when there is only one. Medication use in the OR is a complex process fraught with potential for error. Additional medications could be added to the field during the procedure, and an error could occur if the medication has not been labeled. During a busy procedure, the scrub person may become distracted and mistake one solution for another. In addition, confusion and miscommunication can occur when the scrub person is relieved during a procedure. The surgeon could pick up an unlabeled syringe and administer the wrong medication. The possibilities for error are limited only by the imagination and creativity of Murphy's Law.

Most medication orders are given verbally, and miscommunication between the physician and nurse is a common cause of medication error. Studies show that more than one in 10 medication errors are related directly to the use of incorrect medication names, confusion regarding dosages, and misunderstood abbreviations.(4) As there are few, if any, independent checks in the process, verbal orders leave great room for error.

Operating room personnel should have a policy that specifies the exact steps for safe medication administration. A safe medication administration policy should include, at a minimum, the following specifications.

* The medication is checked by an RN and the scrub person before it is transferred to the sterile field.

* The scrub person labels the sterile medication container and syringe if used on the sterile field.

* The scrub person repeats the name of the medication and the dosage when passing it to the surgeon.(5)

* When repeating the dosage, numbers are expressed in single digits (eg, one-five instead of 15, six-zero instead of 60).(6)

Medication errors resulting in death are estimated to be as high as 140,000 per year, and the National Association of Insurance Commissioners reports that medication errors are the most frequent cause of procedure-related malpractice claims.(7) Careful adherence to safe medication administration practices in the OR is an important aspect of perioperative nursing care.

Question: An orthopedic surgeon at our facility insists that orthopedic and otorhinolaryngologic procedures should not be performed in the same room. These are not total joint procedures, but arthroscopies and sinoscopies. The room is cleaned between procedures with a disinfectant, and the floor is mopped following AORN's "Recommended practices for environmental cleaning in the surgical practice setting." Should orthopedic procedures be treated differently from other surgical procedures?

Answer: As long as AORN's "Recommended practices for environmental cleaning in the surgical practice setting" are followed, there is no need to separate orthopedic and otorhinolaryngologic procedures.(8) There is no justification or research-based evidence that suggests the need for any separation of these types of procedures. The Centers for Disease Control and Prevention also does not make any such recommendation.(9) Until there is published research justifying such a practice, it is not recommended, as it could be extremely expensive and inefficient use of surgical resources that cannot be justified from an infection control perspective.