SafetyNet is AORN’s anonymousreporting system to improve patientsafety in perioperative settings.It is a voluntary reporting tool thatcaptures data about close calls andnear misses in surgical and proceduralsettings. SafetyNet is securelydesigned to promote confidentialityand anonymity with AORN servingas the repository for the data.

AORN believes that, by providing nurses with a safe harborand an easy method for reportingperioperative close calls and near misses, they will be moreencouraged to identify gaps in thepatient care process. The data willbe aggregated, organized, and analyzed to serve as a basis forthe development of new peri-operative practice standards,procedures, and educational programswith a focus on improving patient safety in surgical and procedural environments.

All types of events may be reported toSafetyNet, including the following.• Close calls (ie, events or situations

that could have resulted in accident,injury, or illness if left undetected)

• Lessons learned• Suggested near-miss topics:

• Adverse drug events in perioperative settings(s)

• Blood transfusions resulting insentinel events

• Communication breakdown• Consent issues• Fires in the OR• Implant availability• Incorrect patient• Incorrect procedure• Incorrect site• Nurse staffing and patient

outcome scenarios• Patient hand-off problems• Research protocol • Retained foreign body• Sterility • Technology malfunction

S61JULY 2006, VOL 84, SUPPL 1 • aorn journal •

SafetyNet Near Miss Reporting Tool

Please consider submitting your personal experiences with a near miss to helpAORN inform perioperative nurses of these concerns. A completed sample beginson the next page. There are two ways to contribute to SafetyNet:

• The online form can be accessed at http://www.patientsafetyfirst.org/safetynetor

• Complete the blank form following the example and mail it to AORN—Near Miss 2170 South Parker Road, Suite 300Denver, CO 80231-5711

All information submitted will remain confidential.

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SafetyNet: Near Miss Reporting Tool—SAMPLE1. Please describe the event/situation that occurred in your setting.

Include all contributing factors and details to provide a complete picture of the event.

A 56-year-old male patient scheduled for laparoscopic cholecystectomy with intraoperative cholangiogramwith no other medical or surgical history. Team included attending surgeon, RNFA, surgical technician,circulating RN, and CRNA. This was a routine case, and the experienced perioperative team membershave worked together on this procedure many times. Shortly after the gallbladder was removed, theCRNA verbally requested a check of the insufflator settings. The circulator provided the flow rate at15 mmHg and a pressure of 12 mmHg. The CRNA asked the surgeon to “look around” the abdomenfor any problems since the patient’s heart rate was “rapid (130 bpm) and the QRS looked wide.”The surgeon noted a bulging, reddened area near the thoracic pericardium. The CRNA called for theattending anesthesiologist; the patient’s QRS was becoming progressively wider, and the BP was dropping.The surgeon determined there was pericardial damage from stray electrical current from the electrosurgicalunit. Since this is a small facility, the surgical cardiac team was called (stat) from another nearby facility.Anesthesia stabilized the patient while the surgeon continued to assess the chest cavity for other involvedareas. The circulator ran for the crash cart and chest instruments after putting a page in for extra help.The surgical cardiac team was bringing an electric sternal saw. The assistant director (who had previouscardiac/open heart surgery experience) scrubbed to assist on the case. The cardiac surgeon arrived(15 minutes later), opened the chest, and repaired a 1-cm hole in the ventricle wall with a surgical pledget.The chest was closed with sternal wire, and the patient was transferred directly to the ICU. Later he wastransferred to the neighboring hospital with a cardiac ICU.

2. When did the event take place? Include the day of the week and approximate time.

The patient was scheduled for 2 PM on a Friday. When the event occurred, most staff had left because itwas a quiet day. The call for help came at 3 PM. Staff who had just changed to go home came back tooffer assistance. The remainder of the case proceedings occurred over the on-call shift (no second or thirdOR shift at this facility).

3. Where did this event occur? Describe the place and environment at the time.

This event happened in the main OR of a rural hospital with three ORs. It was a low-volume surgical day.No radio was on, nor was there unusual commotion in the room prior to the event. The case was proceedingas planned until the patient’s vital signs became unstable.

4. Who were the people directly involved in the event, and who were the decision makers?

The staff directly involved were the original surgical team (as listed above), the RN assistant director,the RN director of surgery, and the attending anesthesiologist. The assistant director was the lead sourceperson (she was the only one with cardiac/open heart experience); the anesthesiologist and surgeonworked collaboratively to stabilize the patient until the cardiac surgeon arrived; the director of surgerycoordinated other staff activities and immediate postop needs.

5. How were you involved in this event?

I am the assistant director. I was able to provide expert knowledge in cardiac surgery and helped ready the team for this additional procedure.

6. What was most upsetting to you about this event?

The department’s manual sternal saw could not be found, causing a delay in opening the chest until afterthe cardiac surgeon was available. The attending surgeon has extensive cardiovascular experience andfrequently completed high aortic arch repair. With the proper equipment, the attending surgeon couldhave proceeded to open the chest prior to the arrival of the surgical cardiac team. The equipment that wasneeded could not be found.

Please submit this near miss by sending the completed pages to:

AORN—Near Miss2170 South Parker Road, Suite 300Denver, CO 80231-5711

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SafetyNet: Near Miss Reporting Tool1. Please describe the event/situation that occurred in your setting.

Include all contributing factors and details to provide a complete picture of the event.

A 56-year-old male patient scheduled for laparoscopic cholecystectomy with intraoperative cholan-giogram with no other medical or surgical history. Team included attending surgeon, RNFA, surgical tech-nician, circulating RN, and CRNA. This was a routine case, and the experienced perioperative team mem-bers have worked together on this procedure many times. Shortly after the gallbladder was removed, theCRNA verbally requested a check of the insufflator settings. The circulator provided the flow rate at 15mmHg and a pressure of 12 mmHg. The CRNA asked the surgeon to “look around” the abdomen for anyproblems since the patient’s heart rate was “rapid (130 bpm) and the QRS looked wide.” The surgeonnoted a bulging, reddened area near the thoracic pericardium. The CRNA called for the attending anesthe-siologist; the patient’s QRS was becoming progressively wider, and the BP was dropping. The surgeondetermined there was pericardial damage from stray electrical current from the electrosurgical unit. Sincethis is a small facility, the surgical cardiac team was called (stat) from another nearby facility. Anesthesiastabilized the patient while the surgeon continued to assess the chest cavity for other involved areas. Thecirculator ran for the crash cart and chest instruments after putting a page in for extra help. The surgicalcardiac team was bringing an electric sternal saw. The assistant director (who had previous cardiac/openheart surgery experience) scrubbed to assist on the case. The cardiac surgeon arrived (15 minutes later),opened the chest, and repaired a 1-cm hole in the ventricle wall with a surgical pledget. The chest wasclosed with sternal wire, and the patient was transferred directly to the ICU. Later he was transferred tothe neighboring hospital with a cardiac ICU.

2. When did the event take place? Include the day of the week and approximate time.

The patient was scheduled for 2 PM on a Friday. When the event occurred, most staff had left because itwas a quiet day. The call for help came at 3 PM. Staff who had just changed to go home came back tooffer assistance. The remainder of the case proceedings occurred over the on-call shift (no second or thirdOR shift at this facility).

3. Where did this event occur? Describe the place and environment at the time.

This event happened in the main OR of a rural hospital with three ORs. It was a low-volume surgical day.No radio was on, nor was there unusual commotion in the room prior to the event. The case was proceed-ing as planned until the patient’s vital signs became unstable.

4. Who were the people directly involved in the event, and who were the decision makers?

The staff directly involved were the original surgical team (as listed above), the RN assistant director, theRN director of surgery, and the attending anesthesiologist. The assistant director was the lead source per-son (she was the only one with cardiac/open heart experience); the anesthesiologist and surgeon workedcollaboratively to stabilize the patient until the cardiac surgeon arrived; the director of surgery coordinat-ed other staff activities and immediate postop needs.

5. How were you involved in this event?

I am the assistant director. I was able to provide expert knowledge in cardiac surgery and helped ready theteam for this additional procedure.

6. What was most upsetting to you about this event?

The department’s manual sternal saw could not be found, causing a delay in opening the chest until afterthe cardiac surgeon was available. The attending surgeon has extensive cardiovascular experience and fre-quently completed high aortic arch repair. With the proper equipment, the attending surgeon could haveproceeded to open the chest prior to the arrival of the surgical cardiac team. The equipment that wasneeded could not be found.

Please submit this near miss by sending this completed page to:

AORN—Near Miss2170 South Parker Road, Suite 300Denver, CO 80231-5711

✁

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