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Breaks in Aseptic Technique Require Review of OR Basics

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Some issues crop up before the first incision is made. Because the most common source of pathogenic bacteria is the patient’s endogenous flora, it is essential to prep the patient’s skin by clipping hair from the surgical site, cleansing the skin with an antiseptic product and applying sterile drapes around the surgical site. Survey respondents said they regularly observed improper pre-surgical patient skin prep, including the taboo shaving of patients with razors or not performing a proper cleansing method

Equally important to the pre-operative antisepsis process is the surgical skin prep by the surgeon and members of the OR team. A surgical scrub is performed by surgical team members who will interact with the sterile field or with sterile instruments. The pre-op scrub requires use of an efficacious, persistent antimicrobial soap on the hands and forearms for a longer period of time than used for typical hand antisepsis. Institutional policy usually designates an acceptable minimum length of time required; the CDC recommends at least 2 to 5 minutes of mechanical scrubbing, followed by thorough drying. Alarmingly, many survey respondents reported seeing surgeons severely curtail their scrub time.

When asked what infection control-related breach they see occurring in the OR regularly, ICT survey respondents agreed on a number of issues, including a general break in aseptic technique or contamination of the sterile field precipitated by a number of occurrences such as unscrubbed personnel getting too close to or reaching over the sterile field. Many survey respondents cited hands and instruments being allowed to drop below the level of the sterile field, as well as gowned personnel turning their backs to the sterile field. Some nurses said they saw holes or tears in the sterile packaging of instruments or gloves, while others reported seeing cases set up in the sterile field and then left unattended. One survey respondent noted, “There is a serious lack of understanding about what is sterile, what is clean and how a person’s actions in the OR affect these things.”

“I think the concept of hospitals reviewing ‘periop 101’ issues is so important,” says Sharon McNamara, RN, BSN, MSN, CNOR, director of surgical services at WakeMed Health and Hospitals in Raleigh, N.C. “Due to personnel shortages and other time constraints, people are being rushed through orientation and I don’t think they are necessarily getting a good didactic background on perioperative issues. That may be why when they get into the clinical setting they don’t have the information they need to critically think through situations in the OR. Many institutions like ours conduct an annual back-to-basics course; people may complain that they’ve heard it every year, but each time we try to tackle it differently, such as in a grand-rounds format, for example. The other thing we do is use a root cause analysis (RCA) when we have an issue in the OR, such as a break in aseptic technique. We never used to talk about a lot of what went wrong, but now it’s immensely valuable to have teams talk about what happened so it doesn’t happen again. We share information without pointing fingers.” McNamara continues, “I think the concept of maintaining a ‘just culture’ plays into this – instead of blaming people, you examine whether or not institutional policies and procedures did not support the individual. We also need to address the near-misses, as these are as important as actual breaches. I guarantee you that if it happened to one person on the surgical team, there are probably other people who almost experienced the same near-miss too and could have avoided it, so sharing these experiences and learning from them is critical.”

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