Aseptic technique; electrosurgical safety; abbreviations; instrument markinq tape; medication security

AORN Journal,  May, 2004  by Ramona Conner

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QUESTION: I am a student nurse in the OR and am confused by a practice I observed recently that does not seem consistent with what I have been taught about aseptic technique. I have been taught that if you are not gowned and gloved, you cannot touch something that is sterile. Yesterday, I observed a circulating nurse, who was not in sterile attire, quickly grab something off the sterile back table. When I questioned her, she said that this was acceptable because she touched only the item, not the back table, and she did it quickly. I assume that she meant that because she was so fast, bacteria could not be transferred from her unsterile hand to the sterile field. Is this correct? Would not the sterile field be considered contaminated, or would it still be considered sterile because the item was grabbed quickly?

ANSWER: The idea that an unsterile person can quickly grab an item from the sterile field without contaminating the sterile field is not consistent with the primary principles of aseptic technique. One of the fundamental principles of aseptic technique is that sterile personnel touch only sterile items or areas; unsterile personnel touch only unsterile items or areas. (1) Unsterile personnel must not touch or reach over a sterile field. The circulating nurse always should avoid contact with the sterile area and should be careful to ensure that no unsterile object comes in contact with the sterile field, including hands. It is never acceptable for someone who is not wearing sterile gloves to touch anything on the sterile field, no matter how quickly the item is removed.

Unsterile personnel should exercise caution to ensure that they do not reach over the sterile field with their unprotected arms. Bacterial fallout from the body or clothing is a source of contamination when an unsterile person leans over a sterile field. Reaching over the sterile field requires the unsterile person to move too close to the sterile field. A safe distance from the sterile field should be maintained at all times.

All perioperative personnel must maintain vigilance in regard to sterile areas and point out any contamination immediately. The sterile field should have been considered contaminated by the circulating nurse, and corrective measures should have been taken to restore the sterile field.

QUESTION: A surgeon at our facility wants us to put two electrosurgical unit (ESU) dispersive pads on patients during his orthopedic procedures. He uses two different machines and does not want to wait for the circulating nurse to switch the ESU dispersive pad plug from one machine to the other. Is this an acceptable practice? Does using two machines concurrently increase the risk of an electrosurgical burn?

ANSWER: Two ESUs may be used at the same time if the machines are compatible. Electrosurgical unit compatibility and proper functioning of the electrode monitoring systems should be verified with the manufacturer. Separate dispersive electrodes should be used for each ESU. The dispersive electrodes should be placed as close as possible to their respective surgical sites, and the dispersive pads must not overlap. (2 (p250))

Although two ESUs may be used at the same time, additional care must be taken to ensure that the active electrodes are not activated unintentionally.

Injuries have been reported when an active electrode has been left lying on a patient between uses. The presence of two active electrodes may increase the chance of unintentionally leaving the active electrode that is not in use lying on the patient. The active electrode should be placed in a clean, dry, well-insulated safety holster when not in use. (2 (p248))

QUESTION: I work in a hospital-based eyes, ears, nose, and throat surgery center. The surgeons routinely use the abbreviations "OS" for left eye, "OD" for right eye, and "OU" for both eyes. The hospital risk manager claims that these abbreviations no longer can be used because of a new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard and because they can be misinterpreted. Is this true? We have used these abbreviations for as long as I can remember and have never had any problem understanding what is meant.

ANSWER: The misinterpretation of seemingly common and widely understood medical abbreviations has been reported as a cause of medical error. The Joint Commission's second national patient safety goal for 2004 is to "improve the effectiveness of communication among caregivers." (3) This safety goal consists of two parts, both of which must be satisfied.

Accredited organizations are required to

   Implement a process for
   taking verbal or telephone
   orders or critical test
   results that require a verification
   "read-back" of the
   complete order or test
   result by the person
   receiving the order or test
   result?

In addition, organizations are required to "Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use." (3)