AST Guideline - Best Practices in Alarm Management in the Operating Room

4 Guideline II The CST is responsible for the control of the active electrode (also called electrosurgical or electrocautery pencil or Bovie) when not in use to prevent inadvertent activation to avoid burns to the patient and surgical team, and ignition or puncture of the drapes. 1. The “ buzzing” noise that the electrosurgical unit (ESU) emits indicates when the active electrode is in use. However, it becomes an alarm for the CST to be aware of if the buzzing noise occurs and the surgeon is not using the active electrode. The CST should immediately bring it to the attention of the sterile team in the event that someone is leaning on an active electrode that was left on the drapes. A. The active electrode should always be placed in a dry, well-insulated safety holster when not in use to prevent inadvertent activation or contamination by falling down by the side of the OR table. 4,9,14,16,25 B. The safety holster should be attached to the sterile field using an atraumatic clamp, preferably non-metal. 3,4,16 1) The safety holster should be placed in a location on the sterile field according to the surgical procedure that facilitates easy retrieval by the surgeon. 2) Endoscopic active electrodes are longer than normal and usually do not fit inside the safety holster. In this instance, the active electrode should be placed on the Mayo stand. 4,7,9,16 If the surgeon maintains that the active electrode be placed on the drapes, this should be recorded in the operative record. 3, 4 3) For details regarding electrosurgery refer to the AST Guidelines for Best Practices in the Use of Electrosurgery . Guideline III The surgery department should complete a thorough review of an adverse event involving harm or potential harm to a patient and improper management of an alarm(s). 1. The review should be conducted as a root-cause analysis with a focus on what lead to the occurrence of the adverse event, what P&Ps were not possibly followed/enforced, and how it can be prevented in the future. A. The P&Ps that were not followed should be reviewed for clarity and if they are in- line with current safety trends, and if necessary, revised. B. The surgical team members that were involved in the adverse event should complete continuing education that includes review of the incident and how it could have been prevented. 1) The individuals should provide feedback if they are of the opinion that P&Ps are not clearly stated or other situations are occurring such as alarm fatigue in order for the surgery department to make further improvements in its alarm safety management program. C. The adverse event should be shared with the surgery department staff as a tool for learning without sharing the details of who was involved in the incident.