Often equipment injuries happen because perioperative team members fail to read the manufacturer’s instructions for use [13]. In a classic study by Reason, it was determined that there are 12 common contributing factors to a mistake; the most common was misjudgment, followed by [13]:

Most mistakes are usually organizational in nature (i.e., the origin of the mistake can be traced to a decision made before the mistake happened). Therefore, it is up to individual institutions to understand the behaviors and risk reduction strategies that can be implemented in each unique situation [13]. Facilities can focus on teamwork and communication, issues with equipment and maintenance, and coordination and planning among perioperative team members [14] (for detailed discussion, refer to other chapters on teamwork, communication, or human error).

A comprehensive preoperative assessment should take place prior to the patient being sedated. The process should involve the patient and family members present and should consist of a thorough interview, a review of records, and a head-to-toe assessment. Preexisting conditions should be identified as well as joint issues or implants, decreased range of motion, current or previous fractures, neck or back problems, and any issues with numbness in the hands or arms [2]. The perioperative nurse should have a thorough discussion with the patient and family if any of these conditions are present and how positioning may impact those conditions and discuss how measures will be taken to minimize impact on those conditions [2]. The preoperative assessment checklist is listed in Table 30.1 [10].

A skin assessment should be part of the routine assessment of all patients; additional precautions should be taken to decrease the risk of pressure ulcers in patients who [10]:

When assessing the skin, assess for the following [9]:

Document any areas that meet the conditions above and take additional steps as needed such as placement of extra padding and other pressure-relieving devices and try not to position patients on areas of redness if possible.

With any position, perioperative team members should provide the patient with privacy and dignity while transporting, transferring, and positioning. The entire team is responsible for patient safety and privacy. Safety and privacy considerations by team members are listed in Table 30.2.

The entire perioperative team should be involved in moving and positioning the patient. Care should be taken not to slide or pull the patient which can result in shearing forces or friction on the patient’s skin. Shearing can happen when the patient’s skin stays stationary and the underlying tissues shift or move which can happen if a patient is dragged or pulled without support or if using a drawsheet. Friction occurs when skin surfaces rub over stationary surfaces [10]. The team should be communicating at all times throughout the process, and patient needs should be identified. Tubes, drains, catheters, and other devices should be secured prior to transferring or positioning the patient. Make sure the patient’s body is maintained in alignment and is supported at the extremities and joints and the patient’s airway is maintained. Make sure there are enough people present to transfer and position the patient safely [10].

In all positions, padding should be used to protect the patient’s bony prominences, and the limbs should be positioned to protect them from nerve damage. Most injuries to the nerves are caused by improper patient positioning [15]. There are different types of nerve injuries and they are listed in Table 30.3 [15].

One of the most common positioning injuries is to the brachial plexus (Fig. 30.2) and can occur from several etiologies. The use of a shoulder brace can cause this type of injury when a patient is placed in steep Trendelenburg. If the shoulder brace is placed too lateral, a stretch injury can occur. If placed too proximal, a compression injury can occur due to the shoulder brace pressing the brachial plexus against the first rib. Therefore, the use of a shoulder brace is not recommended [15]. There has not been any proven method of preventing this type of injury when a patient is placed in steep Trendelenburg . A systematic review done by Codd et al. stated that stretching was the principal mechanism of injury, and minimizing the amount of time that a patient remained in the position may help reduce the risk of injury to the brachial plexus. If necessary, returning the OR table to the neutral position when head down may help to reduce the pressure on the nerve [16]. Improper positioning of the upper extremities on arm boards can also cause this type of injury. There is risk of a compression or stretch injury because the brachial plexus runs posterior to the humeral head. If the arm is abducted greater than 90°, then a stretch injury can occur. Patients experiencing this type of injury can experience numbness and tingling or a complete inability to move the arm; wrist drop may also occur [15].

Another common injury that can occur is an injury to the ulnar nerve (Fig. 30.3). The ulnar nerve is located in the olecranon groove as it crosses the elbow. The groove is located posteriorly between the medial condyle of the humerus and the olecranon process of the ulna. The ulnar nerve is covered by soft tissue leaving it vulnerable to injury. An ulnar injury can occur when the arms are tucked at the patient’s side. If the arms are not correctly positioned and secured, the arm can migrate down and press against the edge of the table causing the nerve to be compressed. Before tucking a patient’s arms, the forearm should be pronated so that the olecranon groove is rotated both outward and lateral which will protect the nerve from compression. Placing extra padding at the elbow before the arms are tucked will add additional protection [15]. Additionally when placing the patient’s arms on arm boards, the forearm should be supinated to prevent compression of the ulnar nerve, and extra padding can be applied to the elbow.

Other safety considerations are presented in Table 30.4.

Injury to a patient’s eyes is of particular concern; direct pressure on the eye should be avoided to reduce the risk of central retinal artery occlusion and other damage to the eye such as a corneal abrasion. Patients who are at increased risk for developing postoperative visual loss are those that are undergoing prolonged procedures greater than 6.5 h and those who experience a blood loss greater than 44.7 % of estimated blood volume or those who are positioned prone [10].

Patients at risk for this injury should be positioned with their heads level with or higher than their hearts, and the head should be maintained in a neutral forward position without significant flexion, rotation, or extension. The use of a horseshoe headrest may increase the risk of injury [10].

To reduce the risk of injuries to the extremities, the safety precautions that should be followed [10] are shown in Table 30.5.

The supine position is the most commonly used surgical position (Fig. 30.4). Almost every patient is initially placed in the supine position for induction and then repositioned as necessary. Many surgeries performed in this position are general surgery; reconstructive or plastic surgery; procedures involving the anterior chest, pelvis, or epigastrium; orthopedic procedures on the knees, feet, hands, and forearms; and some neurosurgical procedures such as anterior cervical or cranial procedures [2]. When a patient walks back to the procedure room and then lies down in the supine position, they experience a decrease in vascular resistance, heart rate, functional residual capacity, and total lung capacity. There is an advantage to patients positioning themselves in the supine position as they can verbalize any discomfort, and adjustments can be made as needed such as placing a pillow under the knees. As noted previously, there is an increased pressure on the elbows, heels, and sacrum. The ligaments of the spinal column relax with induction agents and can result in back pain. Additionally, the back of the head is under pressure, and patients can experience pressure alopecia [2].

If patients do not walk back to the procedure room but are transported on a stretcher, a lateral transfer will be performed. Use a lateral transfer device such as a slider board or air-assisted transfer device (Figs. 30.5, 30.6, and 30.7). The following recommendations should be followed regarding team members required to safely transfer patients [10]: