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Nursing and Patient Safety in the Operating Room

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JAN ORIGINAL RESEARCH

Nursing and patient safety in the operating room

Herdis Alfredsdottir & Kristin Bjornsdottir

Accepted for publication 30 July 2007

Correspondence to H. Alfredsdottir: A L F R E D S D O T T I R H . & B J O R N S D O T T I R K . ( 2 0 0 8 ) Nursing and patient safety in

e-mail: herdisal@landspitali.is
H. Alfredsdottir MNSc RN CNOR
Clinical Coordinator
Operating Room, National University
Hospital, Reykjavik, Iceland
K. Bjornsdottir EdD RN
Professor
Faculty of Nursing, University of Iceland,
Reykjavik, Iceland
the operating room. Journal of Advanced Nursing 61(1), 29–37
doi: 10.1111/j.1365-2648.2007.04462.x
Abstract
Title. Nursing and patient safety in the operating room
Aim. This paper is a report of a study to identify what operating room nurses
believe influences patient safety and how they see their role in enhancing patient
safety.
Background. Research in health care shows that work experience, communication
and the organization of work are key factors in patient safety. This study draws on
Reason’s definitions of active and latent errors to conceptualize the complex issues
that affect patient safety in the operating room.
Method. The study reported here is part of an action research project at a university
hospital in Iceland. Semi-structured interviews were conducted in 2004 with eight
nurses, followed by two focus groups of four nurses each in 2005. Data were
analysed using interpretive content analysis.
Findings. Securing patient safety and preventing mistakes were described as key
elements in operating room nursing by all survey participants. In the interviews, the
nurses identified the existing culture of prevention and protection that characterizes
operating room nursing as crucial in enhancing safety. The organization of work
into specialty teams was considered essential. Increased speed of work in an envi-
ronment where enhanced productivity is imperative, as well as imbalance in staffing,
was identified as the main threats to safety.
Conclusion. Operating room nurses have a common understanding of the core of
their work, which is to ensure patient safety during operations. The work envi-
ronment is increasingly characterized by latent error, i.e. system-based threats to
patient safety that can materialize at any time. Interventions to enhance patient
safety in operating room nursing are needed.

Keywords: adverse events, empirical research report, focus groups, incident

reporting, interviews, nursing, operating room nursing, patient safety

1990s (Brennan et al. 1991), which concluded that mistakes

Introduction
Patient safety has been discussed extensively in both medical
and nursing literature in recent years. Enhanced focus on
safety is often attributed to findings from a study on error in
health care in the United States of America (USA) in the early
were much more common than previously believed. Subse-
quently the Institute of Medicine (IOM) in the USA issued a
comprehensive report on error and ways to prevent mistakes
in health care (Kohn et al. 2000). The IOM report has had a
wide impact and its findings have been addressed in the

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 29

H. Alfredsdottir and K. Bjornsdottir
nursing literature by number of authors (Cook et al. 2004,
Page 2004, Crigger 2005). Among other things the report
calls for a shift in the conceptualization of the sources of
mistakes from blaming individuals to analysing system
failures, i.e. from a focus on active failures to latent failures.
Background
This shift in conceptualization of the nature of error in the
IOM report reflects a general trend in addressing safety often
attributed to Reason (1990). Reason distinguished errors into
two categories, active and latent failure. Active failure is error
made by those at the sharp end of practice, i.e. by the
employee that performs the task. The effect is felt almost
immediately. Latent failures are system-based mistakes, such
as decisions that lead to insufficient staffing, excessive
workload or faulty maintenance of equipment. Latent
failures can lie dormant in the system for some time,
becoming active under certain circumstances (Reason 1990).
As in other fields the discussion in the nursing literature has
been influenced by the above shift from focusing on the
individual practitioner to the organizational context as the
source of error (Benner et al. 2002). The Association of
periOperative Registered Nurses in the USA has identified
how nurses’ clinical and organizational expertise can help
find and correct system-related errors by simplifying and
standardizing work processes as well as improving the work
environment (AORN 2005). Incidence reporting has been
identified as an important method to find and analyse system
failures (Dunn 2003a,b). Similarly, information technology
has been suggested as a helpful way to analyse systems and to
find system errors (Simpson 2005), as well as improving
practice by facilitating the sharing of information and the use
of checklists and protocols to reduce reliance on memory
(AORN 2005).
Studies addressing safety and error in health care have been
scarce. Most of them attend to both active and latent errors.
Lack of communication, as well as reluctance to admit the
effect of fatigue on work performance, has been found to be
characteristic of the work environment within health care
(Sexton et al. 2000). In two studies in Britain nurses identified
the most common causes of error to be lack of practice, heavy
workload and poor judgement (Meurier et al. 1997, 1998).
Silén-Lipponen et al. (2005) studied error and teamwork in
operating room nursing in three countries (Finland, the UK
and the USA), and concluded that experience, communica-
tion and shared responsibility in teams, and the duty of
management to address circumstances that lead to error are
important factors in patient safety. The study presented in
this paper is explorative. It was designed to reflect issues that
30  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
have emerged in previous studies on safety and its concep-
tualization was based on Reason’s definition of active and
latent error.
The study
Study context
The work on which this paper is based took place at a
university hospital formed in 2000 when two of the main
acute care hospitals in Iceland merged. The merger led to a
fundamental reorganization of operating room services, to
which the nursing staff needed to adjust. In an attempt to
clarify the values and aims of operating room nursing at the
hospital, a questionnaire was sent to all operating room
nurses. They were asked to describe the main characteristics,
goals and nature of their work. Protecting and enhancing
patient safety emerged as the core of operating room nursing.
Following these findings, the decision was made to design an
action research project with the aim of identifying and
developing ways to enhance patient safety during surgery at
the hospital (Holter & Schwartz-Barcott 1993, Hampshire
2000). The study presented in this paper is part of that
project. Its aim was to identify factors that nurses view as
enhancing and threatening to safety, with the intention of
using the findings as a basis for changes in the organization of
operating room nursing that the nurses identified as neces-
sary.
At both departments that participated in the study,
operating room nursing has for a number of years been
organized in specialized teams of nurses who work in close
collaboration with surgeons in each speciality. This special-
ization is considered beneficial to patient safety. The nurses
are experienced and skilled in specific operations and have
advanced knowledge of their fields of surgery. The standard
working week is 40 hours, but most nurses will be on call
some days of the month in addition. It is quite common for
nurses to be asked to work extra shifts in addition to the
standard work schedule.
Following the merger of the operating room services at the
two hospitals, some of the nurses had to choose between
moving to a new setting or changing specialities, which meant
considerable readjustment. In addition, the operating room
departments faced a number of challenges. The workforce
had been stable for many years and most of the nurses had
extensive experience, but many of them were now preparing
for retirement.
In addition to these changes in the work group, the work
environment has changed in fundamental ways. Demands for
productivity and efficiency have increased and the time for
JAN: ORIGINAL RESEARCH
staff development and work on developmental projects is
more limited. Operations are also larger and more compli-
cated, as smaller procedures are now performed in private
clinics outside the hospital. The use of minimally invasive
surgery, in addition to progress in anaesthesia, has reduced
the risks involved in surgery, allowing more fragile patients to
be operated on. As a result, some patients undergoing surgery
are older and in poorer health, and need careful monitoring.
Stage 1. Preliminary survey
Aim
The aim of the preliminary survey was to identify how
operating room nurses understand the goals, values and
characteristics of their work, which may play a critical role in
identifying indicators for quality operating room nursing
(Norman et al. 1992).
Design
A survey was designed using a modification of the critical
incident technique which stresses clear and concise descrip-
tions (Flanagan 1954, Alfredsdottir 2003).
Method
Questionnaires were sent to all the operating room nurses
(N = 60) who were on call from 25 April until 5 May, 2003.
The response rate was 50% (n = 30).
Participants were asked to answer three open questions: (1)
What do you think ought to be the main goals of nursing care
in the operating room? (2) What do you think is most
important in the services provided by operating room nurses?
and (3) How would you describe the characteristics of
operating room nursing in your workplace as currently
practised? The questions were ordered so that they led from
the general to the more specific and concrete.
Ethical considerations
Permission to carry out the survey was granted by the Head
of Nursing at the division. Letters of introduction were sent
with the questionnaires, in which the aim of the survey was
explained, anonymity promised and participation encour-
aged. Completed questionnaires were put in envelopes and
given to the unit secretary.
Data analysis
Data analysis, following the critical incident technique, is
inductive, aiming to classify key findings into categories
(Norman et al. 1992). The answers were read and reread to
identify factors that indicated what the nurses saw as the
essence of operating room nursing. Categories and themes
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Nursing and patient safety in the operating room
were formulated, moving from the general to the more spe-
cific.
Findings
The core of operating room nursing was identified as patient
safety and the skilful and knowledgeable work performed
by nurses vis-à-vis ensuring a safe transition through sur-
gery. Its goal was described as providing patient-centred
nursing so that patient safety and a positive outcome were
ensured. When asked what characterized their nursing,
participants described how a patient undergoing surgery is
vulnerable and needs to be taken care of by skilled profes-
sionals who use nursing interventions in a preventative
manner.
Stage 2. Interview and focus group study
Based on the findings of this survey, a qualitative study
involving semi-structured interviews and focus group discus-
sions with operating room nurses was designed.
Aim
The aim of this study was to identify what threatens and
enhances patient safety and how operating room nurses see
their role in ensuring safety. The research questions in this
part of the project were:
• Which factors in the organization of the operating room
do operating room nurses describe as influencing patient
safety?
• How do operating room nurses describe their contribu-
tion to patient safety?
Participants
Two purposive samples of nurses were recruited, one for the
individual interviews and the other for the focus groups. The
total number of participants in the study was 14, as two
nurses who had previously participated in interviews also
took part in the focus groups. These two nurses showed a
special interest in the project and requested to be allowed to
participate in the whole process.
The study was introduced at staff meetings in operating
departments, and voluntary participation was requested.
Volunteers were asked to contact the head nurse on their
unit, who then decided who would participate, based on the
inclusion criteria. These were a minimum of 5 years’ work
experience, variation in specialty teams and an interest in
participating in the project by sharing knowledge and
experience. The age of participants reflected the average
age (49Æ7 years) of nurses working in the departments in
question.
31
H. Alfredsdottir and K. Bjornsdottir
The interview sample was composed of eight Registered
Nurses, all certified operating room nurses. Four nurses were
recruited from each department. Their age was 45–54 years
and their length of work experience ranged from 11 to
30 years. The same inclusion criteria were used for partici-
pation in the focus groups, although the criterion for years of
experience was lowered to include the views of those with
less experience to broaden the viewpoints accessed.
Two focus groups of four nurses were established, one
from each department. Their age range was 42–51 years and
their length of work experience varied from 3 to 21 years. All
were Registered Nurses and all except for two of the focus
group participants were certified operating room nurses. The
main purpose of the focus groups was: (1) to reinforce our
analysis of the interview data and (2) to discuss initiatives to
increase patient safety.
Data collection
The semi-structured interviews took place in the autumn of
2004. Patient safety, work environment and adverse events
were the focus of the interviews, which were conducted using
an interview guide that was developed based on findings from
the survey and with reference to the literature review (see
Table 1). Participants were encouraged to express their views
freely. The goal was to chart the situation and identify factors
Table 1 Interview guide
1. How would you describe nursing practice in the department?
2. If you consider the last 5 years, do you see any changes in
nursing practice? If so, what kind of changes?
3. How would you define the aim of teamwork in
the department?
4. Are there any changes that need to be done
concerning teamwork?
5. How would you describe co-operation in the department?
6. Do you detect any weaknesses in co-operation?
7. How is patient safety in nursing secured in the department?
8. Do you detect any changes in the last 5 years concerning
patient safety?
9. Do you ever worry about patient safety at the department?
If yes, how?
10. Are there any factors in your work environment that could
endanger patients?
11. What is your assessment of nursing skill at the department?
12. What do you consider most important in securing
patient safety?
13. Have you experienced or witnessed a mistake or near miss in
your nursing environment?
a. If yes, was the incident reported?
b. How was it handled?
c. Were you satisfied with the handling?
14. If you were involved in a mistake or a near miss, how
should it be handled?
32  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
in the work environment that influence patient safety. The
interviews were audiotaped and lasted approximately 1 hour
each.
An interview guide that reflected findings from interview
analysis was designed for the focus group discussions that
took place in January to February 2005 (see Table 2). Free
exchange of opinion was encouraged as well as ideas for
interventions to enhance patient safety (Kitzinger 1995, Kidd
& Parshall 2000).
Ethical considerations
The study was approved by the Ethical Review Board at the
hospital where the research took place. Before the interviews
and the focus group meetings the nurses were handed a letter
introducing the purpose of the study. Confidentiality was
promised, and the right to withdraw from the study was
emphasized. Participants were also assured that participation
would not have any impact on their working relationships.
All participants signed an informed consent form.
Data analysis
Texts from interviews and focus groups were interpreted
separately and characterized by an integrated process of data
collection, analysis and interpretation (Sandelowski 1995,
Kvale 1996), using interpretive content analysis (Baxter
1994, Graneheim & Lundman 2004).The units of analysis
were every audiotaped interview and focus group discussion.
Initially, audiotaped interviews were listened to and
compared with the transcripts. Then each interview was read
and reread with the intention of gaining a sense of underlying
key phrases before starting comparison with other interviews.
Transcripts from focus group discussions were analysed using
the same technique. Quotations from texts that were repre-
sentative for the findings were extracted into statements and
then condensed into a meaning unit that was compared with
other meaning units. Statements that had a common meaning
were sorted into 11 main categories constituting the manifest
content. Categories that seemed to be related were then
Table 2 Focus group guide
1. Factors that strengthen nursing in the operating room
Characterized by preventative measures to protect the patient
Expertise in teams
Nurses with long experience in operating room nursing
2. Factors that threaten
Increased speed and productivity
Control of circumstances
Staffing and the work environment
3. How can we best deal with errors in a way that supports the
victims and will lead to learning and prevention in the future?
JAN: ORIGINAL RESEARCH
linked together in eight themes expressing the latent content
of the text or the underlying meaning of what was said
(Graneheim & Lundman 2004).
The initial analysis was performed individually by both
authors. Minor discrepancies were discussed and a consensus
was reached as to the most valid interpretation. An external
expert in qualitative research read the interviews and went
over the analysis to ensure rigour. The focus groups served a
further role in enhancing the rigour. By discussing the
findings from the interview data in the focus groups, it was
hoped that the trustworthiness of the analysis would be
supported. Rigour and trustworthiness were also sought by
the multimethod approach, i.e. a survey that was the initial
step of the study, interviews and focus groups (Bellman
2003).
Researcher involvement
The project was initiated by the first author, who had been
a head nurse at one of the operating departments for 5 years
in addition to participating extensively in curriculum
development and teaching operating room nursing. At the
time of the study, she had leave of absence from her head
nurse position. The survey described above provided the
base for what has since become a joint effort among oper-
ating room nurses at the hospital. Doing research in one’s
own field of practice can be difficult and fraught with
complicated issues of power and ethics. Many researchers
have discussed this and stressed the importance of describ-
ing the role of the researcher so that readers can make their
own judgement about the rigour of the study being de-
scribed (Turnock & Gibson 2001). It is our view that this
closeness enhanced open communication in the interviews
and the researcher’s knowledge of the field was a strength-
ening factor in the study.
Findings
Enhancing patient safety
All the nurses who participated in the interviews described
feeling responsible for the well-being of their patients. They
often talked about their work as protecting the helpless, with
prevention being of key importance in ensuring safety.
Creating an environment of warmth, respect and safety for
patients was essential to them, and they described how they
try to create a quiet, relaxed and friendly atmosphere when
greeting a patient. Focusing on the patient is central, and they
try to keep conversations between themselves to a minimum
while the patient is still awake. Three factors emerged as
most important in enhancing patient safety: preventive
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Nursing and patient safety in the operating room
thinking, knowledgeable and experienced workers supported
by good teamwork, and mutual trust based on many years of
co-operation.
Thinking ahead: prevention of mistakes – the core of
operating room nursing
All participants described how prevention is always at the
core of their work. This means thinking ahead, trying to
imagine everything that can go wrong, and taking steps
to prevent such occurrences by using guidelines and
checklists:
Our nursing aim is prevention, yes, preventing surgical complica-
tions. I think that’s our main purpose…it embraces everything.
They also described how they had to know the background
of the patient, and their particular vulnerability and
fragility that might increase risk during the operation.
Thus, good preoperative patient-centred information that
reflects individual patients’ needs and vulnerabilities is
essential. They described how they do not interview
patients undergoing surgery themselves, apart from doing
a standardized admission check, but rely on information
from the patients’ records, particularly from the anaesthesia
team. A number of participants said that in some situations
they do not have all the information required preopera-
tively, especially in cases of specific patient needs. They
suggested that better preoperative information would
ensure patient-centred nursing, continuity of care, and
better and more efficient preparation for the surgical
operation.
Expertise in teams
The importance of teams in enhancing patient safety was
mentioned by all participants. By dividing the work into
teams, operating room nurses develop advanced knowledge
of particular operations and a high level of performance. As
one of them described:
It’s [nursing] more professional, our nursing is better after we
introduced teamwork in the operating room. You know the skills and
knowledge of your team colleague, everyone knows what to do and
things go smoothly. We’re just more competent.
Although teams were seen as important for safety, and
teamwork was mentioned as one of the strengthening
elements of safety in the operating room, focus group
participants identified potential weaknesses that needed to
be attended to. The teams are often unequally staffed; some
are under-staffed and often need support from other teams.
Participants felt that this needed to be attended to by
managers.
33
H. Alfredsdottir and K. Bjornsdottir
Mutual trust and co-operation
The nurses working in the operating room are in general
experienced and represent a stable workforce. Many, al-
though not all, have specialized education in operating
room nursing and have worked in this area for many years,
even decades. The relationship among the nurses working
in both departments was described as supportive. They
know each other personally and have developed relation-
ships of mutual trust and co-operation. As one participant
described:
You know your colleagues very well and it’s kind of another family
when you have worked together for such a long time.
Many participants described a positive feeling of belonging to
a team. They know what to expect from their co-workers and
have learned to deal with different personalities. However, it
should also be noted that some drawbacks to teamwork were
mentioned, such as lack of criticism and reluctance to change
work processes.
Threats to patient safety
A number of issues were identified as threats to patient safety.
These relate to the work environment: the fatigue that builds
up over time, concentration difficulties, lack of control over
situations, insufficient staffing and unclear expectations
towards staff. The themes discussed in this section give rise
to worries that there may be latent failures in the work
environment that may lead to active failures (Reason 1990).
Worries about demands for increased speed and productivity
The hospital portrays itself in terms of productivity, as is
reflected in the increased number of operations performed
and the reduction of waiting lists. The nurses described how,
within this environment, they are expected to do more than
before, and in less time. The time schedule for operations is
tight, and many patients will be waiting for their operations.
The pace must be kept up at all costs. The work processes are
timed and, while the surgical procedure cannot be rushed, the
nurses sense pressure to reduce time for preparation and time
between operations.
In general, they felt that they were still coping, but they
worried about the future and wondered how long they could
carry on working like this, i.e. feeling under pressure most of
the time. They are always racing against time, so they are
mentally exhausted at the end of the shift. One nurse
described how difficult it becomes to try to slow down:
You know that there are patients in need of operations and they have
been waiting, maybe dreading the procedure, and they have made
34
arrangements because they are scheduled for the operation and it’s
difficult to have to make a decision that changes that schedule.
Many said that they feel addicted to the tension at work.
They enjoy the thrill of the pace, and want to be efficient, but
at the same time feel that it is at the cost of personal
exhaustion. As one said:
Usually I am very, very tired when I get home. I am not tired while at
work – it is fun to be at work and I like my job and I’m very proud of
it – but I am very tired when I get home.
Constant concentration
This leads into the next theme, which reflects the nature of
operating room nursing. Participants described the work as
complicated and demanding full, undivided concentration.
Forgetting something can be detrimental, and being tired is
cause for alarm:
You have to be alert all the time, being tired isn’t an option. This kind
of work demands full attention.
The pressure to increase the speed of the work and the
number of operations during a shift was often mentioned as
a serious threat to the ability to concentrate and to foresee
and prevent errors. To withstand the pressure and ensure
maximum performance, the nurses have become more
cognizant of methods of relieving stress. Many said that
they use exercise to reduce the tension that they experience
after work and to prepare for the next shift. Staying fit is for
many of them imperative to cope with the pressure
experienced at work.
Lack of control of circumstances
When asked what they thought causes error or mistakes, the
nurses mentioned ignorance, lack of experience, distraction
and haste. As one participant described:
When you try to do too many things at once in a short time with little
prior experience, you run the risk of making a mistake.
This was experienced most acutely when they were placed in
a novel situation. Many of the participants are very experi-
enced, but they also feel that they have become specialized
and that their expertise varies greatly depending upon the
operations in which they participate.
Staffing and the organization of work
Sufficient staffing was a topic that emerged repeatedly both in
individual interviews and in the focus group discussions. As
the following quote from a nurse reflects, to function at the
speed currently expected, staffing must be adequate and the
team must be competent:
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Nursing and patient safety in the operating room

The work must be organised. There are some surgical operations that Although serious failure or errors that have irreversible
need special staffing and when this happens those resources must be consequences have been uncommon at the hospital where
available…you must have the nurses who are trained for those the participants work, they discussed changes in the content
operations. and organization of their work that raise questions about
their ability to ensure safety in the future. They described
Participants described how imbalance in staffing, which may
how the demands for higher productivity and attempts to
be either under- or over-staffing, may lead to unsystematic
keep up with waiting lists have increased the speed of work
preparation or distraction. They stressed that the division of
in the operating room, leading to experiences of pressure.
labour and responsibility within the team needs to be clear.
Operations have also become more complicated and tech-
Plans must be made for breaks, and special caution is
nically challenging, which has called for new knowledge and
required around changes of shift. Rules on routine procedures
skills, while time for staff development has decreased.
such as checking information and counting must be followed
However, as the demands have increased, the work force,
at all times.
which until recently has been stable, has begun to show
signs of vulnerability. Due to lack of trained nurses and an
Addressing adverse events and mistakes increase in sick leave, imbalance in staffing has increased.
All of this was identified as potential sources of risk of
In the literature, incident reporting is commonly identified as
mistakes by the participants, or what Reason (1990) refers
a key method in addressing system-based errors. By reporting
to as latent error.
mistakes, errors are detected, analysed, discussed and
In many ways, our findings coincide with those of a
attended to. A reporting system for adverse events has been
recent multinational study carried out in Finland, the USA
in operation at the hospital for a number of years, although it
and the UK (Silén-Lipponen et al. 2005). In both studies,
is believed that incidents are grossly under-reported. Many of
teams function in enhancing safety. The stability of teams is
the nurses expressed scepticism about the value of formal
seen as important in advancing skill, which may minimize
incidence reporting, and felt that it might easily lead to
errors. The nurses in both studies describe working under
blaming the victim. However, this does not necessarily mean
constant pressure, while at the same time having to be alert
that incidents are not attended to. The nurses described how
and provide quality care and safety for the patient.
incidents are commonly brought up in the teams, where
Occupational-related stressors such as heavy workload,
nurses feel they can trust each other. In this way they provide
shortage of staff and pressure to work faster have also been
support for each other, while also exploring what went
shown to affect nurse anaesthetists’ concern for patient
wrong and how it might have been prevented, resulting in a
safety. They, like the nurses in our study, link their concern
change of task performance.
among other things to lack of time for preparing and
reviewing patient-centred information before each surgery
Discussion (Perry 2005).
The findings reported here and from other studies should
Ensuring patient safety is the main focus of operating room
cause alarm among managers and policy makers. There are
nursing, as described by the participants in this study. The
strong indications that operating room nursing is under
data also gave insight into what nurses see as enhancing
considerable strain, which may in the long run lead to
and threatening patient safety during operations. To
increased errors. Caution must be exercised in attempts to
enhance safety, the nurses organize their work with the
increase productivity.
aim of preventing mistakes from happening. By specializing
A number of strategies to improve safety were discussed
into teams they develop advanced knowledge of operations
among the participants in this study, some of which have
in particular areas and develop the skills needed for safe
also been described in the literature. Operating room nurses
practice. Working in teams was also considered positive for
use checklists and many participants mentioned them as
work morale and a sense of mutual trust and co-operation
helpful when in a constant hurry. However, they felt that
which again was described as enhancing safety. Compre-
the exchange of information at the change of shifts or
hensive knowledge of each patient’s individual needs
during breaks had to become more formalized and secure.
was also seen as highly important. In general, the
Incident reporting is a strategy that has been described in
nurses demand high standards among themselves and
the literature as a tool to identify system weaknesses (Dunn
practices are designed to detect potential errors before
2003a,b). Its purpose is to gather and analyse confidential
they occur.

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 35

H. Alfredsdottir and K. Bjornsdottir
What is already known about this topic
• Patient safety has received a great deal of attention in
health care but there has been relatively little empirical
research on this topic.
• Patient safety has been linked to factors in the work
environment such as communication and management
decisions.
• Nurses have identified the most common causes of
error as lack of knowledge, information and supervi-
sion, heavy workload and poor judgement, which may
be lead to both active and latent errors.
What this paper adds
• Operating room nurses identify securing patient safety
as their most important nursing intervention.
• Patient safety is strengthened by a culture of preven-
tion and protection and the organization of work into
specialty teams, while demands for enhanced produc-
tivity and staffing imbalance can threaten patient
safety.
• Nurses’ clinical and organizational expertise can be
used to correct latent errors, avoid active errors and
improve the work environment.
information so that future incidents can be prevented.
Rather than being used as a method to identify individuals
who are incompetent, the focus is on the system as a whole
and represents a new way of thinking about nursing error
management (Johnstone & Kanitsaki 2006). Incidence
reporting has been in operation at the hospital were this
study took place for a number of years, but this is not
working. Practitioners do not report what happens and, as
this study revealed, they are sceptical about confidentiality
and the purpose of the system.
Technical competence and caring for the patient are
closely connected elements of everyday work in the
operating room, but have sometimes been portrayed as
oppositions. Operating room nurses have experienced
confusion about their image and the core of their work
(Tanner & Timmons 2000, Sigurdsson 2001, Riley &
Manias 2002, Bull & FitzGerald 2006). Therefore, it is
interesting to note that the nurses who participated in this
study had a clearly articulated aim, which was to
ensure patient safety during surgery. These findings
seem to suggest that patient safety should be at the centre
of operating room nurses’ conceptualization of their
practice.
36
Study limitations
The data on which this paper is based came from a sample of
operating room nurses working at a university hospital in
Iceland. Clearly, this hospital does not reflect the organiza-
tion and performance of operating room nursing universally.
In addition, the qualitative research design does not warrant
generalization to all operating room nursing. Despite these
limitations, the findings give a valuable insight into the nature
of patient safety in the operating room and support findings
from other studies (Silén-Lipponen et al. 2005).
Conclusion
In light of the main findings of this study, which indicate that
operating room nursing is under considerable strain and that
the work environment is increasingly characterized by latent
error, it seems imperative to conduct further research on the
impact that the demand for increased productivity has on
patient safety during operations.
Author contributions
HA and KB were responsible for the study conception and
design and the drafting of the manuscript. HA performed the
data collection and HA and KB performed the data analysis.
HA obtained funding and HA and KB provided administra-
tive support. HA and KB made critical revisions to the paper.
KB supervised the study.
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