Spencer Robertson is a 4-week-old frail neonate who had a rectal exam and dilatation under anesthesia following prior surgery for imperforate anus.When the drapes were removed from Spencer,the perioperative nurse noted an area of redness,swelling,and abrasions on the buttocks of the patient.Spencer had been positioned prone for 20 minutes.The nurse who noted the skin condition had relieved the circulating nurse and quickly reviewed the perioperative record and patient chart,but had not seen the patient before positioning.Which of the following safety factors may have contributed to this event?

Question

Quizplus · Accepted Answer

All of the above factors could have collectively contributed to the skin injury.The skin condition could also have been present on admission to the OR and not seen or noted.Findings from sentinel event reports over the last 2 decades demonstrate that the individual efforts of the best nurses,surgeons,and anesthesia providers,combined with a recognized need for teamwork,may not be sufficient in the perioperative setting.

Spencer Robertson Is a 4-Week-Old Frail Neonate Who Had a Rectal