Evidence for the clinical standards

  1. Reason J. Safety in the operating theatre – Part 2: Human error and organisational failure. BMJ Qual Saf 2005:14;56–60 [cited 2017 September]. Available from: PMCID: PMC1743973
  2. NSW Health. PD2013_054. Management of instruments, accountable items and other items used for surgery or procedures [Internet]. Sydney: NSW Health Department; 2013 [cited 2017 September]. Available from: www1.health.nsw.gov.au/pds/ ActivePDSDocuments/PD2013_054.pdf
  3. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards
  4. Staunton P, Chiarella M. Nursing and the law. 5th ed. Sydney: Churchill Livingstone; 2003. 
  5. Denholm B. Clinical issues: Counting miscellaneous items, counting during organ procurement, counting for sequential procedures; influenza vaccine; reprocessing. AORN J 2006;83(1):231–239 [cited 2007 November 12]. Formerly available from: www.aorn.org/ journal/2006/janci.htm 
  6. Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg 1996;224(1):79– 84. DOI: 10.1097/00000658-199607000-00012
  7. Victorian Surgical Consultative Council (VSCC). Fatigue during long operations: VSCC guidelines [Internet]. Melbourne: VSCC; 2005 [cited 2007 November 12]. Formerly available from: www.health.vic.gov.au/vscc/ downloads/immediate-counselling-surgeons.pdf
  8. Standards Australia. AS 4369.1: 1996 (withdrawn). Surgical dressings. Part 1: Single use x-ray detectable abdominal sponges. Sydney: Standards Australia; 1996. 
  9. Standards Australia. AS 4369.2:1996 (withdrawn). Surgical dressings. Part 2: General purpose single use woven gauze swabs. Sydney: Standards Australia; 1996. 
  10. Knepil GJ, Blackburn CW. Retained throat packs: Results of a national survey and the application of an organisational accident model. Br J Oral Maxillofac Surg 2008;46(6);473–476. DOI: 10.1016/j.bjoms.2008.02.005
  11. World Alliance for Patient Safety. Implementation manual surgical safety checklist. 1st ed. Geneva: World Health Organization; 2008 [cited 2020 March 11]. Available from: www.who.int/ patientsafety/safesurgery/tools_resources/ SSSL_Manual_finalJun08.pdf
  12. Najjar MF, Kimpson J. A method for preventing throat pack retention. Anesth Analg 1995;80(1):208–209. DOI: 10.1097/00000539-199501000-00041
  13. Stone JP, Collyer J. Aide-memoir to pharyngeal pack removal. Anesth Analg 2003;96(1):304. DOI: 10.1097/00000539-200301000-0006
  14. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348(3):229–235. DOI: 10.1056/NEJMsa021721
  15. Norton EK, Martin C, Micheli AJ. Patients count on it: An initiative to reduce incorrect counts and prevent retained surgical items. AORN J 2012;95(1):109–121. DOI: 10.1016/j.aorn.2011.06.007
  1. Occupational Health and Safety Administration (OHSA). Anaesthetic gases: Guidelines for workplace exposure [Internet]. Washington DC: OHSA; 2000 [cited 2020 March 1]. Available from: www.osha.gov/dts/osta/ anestheticgases
  2. Barker JP, Abdelatti MO. Anaesthetic pollution: Potential sources, their identification and control. Anaesthesia 1997;52(11):1077–1083.   DOI: 10.1111/j.1365-2044.1007.224-az0359.x
  3. Safe Work Australia. Guidance on the interpretation of workplace exposure standards for airborne contaminants. [Internet]. Canberra: Safe Work Australia; 2013 [cited 2020 March 1]. Available from: www.safeworkaustralia.gov.au/system/files/ documents/1705/guidance-interpretation-workplace-exposure-standards-airborne-contaminants-v2.pdf
  4. Australian and New Zealand College of Anaesthetists (ANZCA). PS31 Guidelines on checking anaesthesia delivery systems [Internet]. Melbourne: ANZCA; 2014 [cited 2020 March 1]. Available from: www.anzca.edu. au/documents/ps31-2014-guidelines-on-checking-anaesthesia-deliv.pdf
  5. Morgan GE, Mikhail MS, Murray, MJ. Clinical Anaesthesiology. 4th ed. New York: Lange/McGraw-Hill; 2005. 
  6. Standards Australia. AS 1668 Set-2016 The use of ventilation and air conditioning in buildings Set. Sydney: Standards Australia; 2016. 
  7. Standards Australia. AS/NZS 1668.1:2015/Amdt 1:2018 The use of ventilation and air conditioning in buildings Fire and smoke control in buildings. Sydney: Standards Australia; 2018. 
  8. Australian and New Zealand College of Anaesthetists (ANZCA). PS55 Recommendations on minimum facilities for safe adminsitration of anaesthesia in operating suites and other anaesthetising locations [Internet]. Melbourne: ANZCA; 2012 [cited 2020 March 1]. Available from: www.anzca.edu.au/ documents/ps55- 2012-recommendations-on-minimum-facilities-fo.pdf
  9. Australian and New Zealand College of Anaesthetists (ANZCA). PS8 Statement on the assistant for the anaesthetist [Internet]. Melbourne: ANZCA; 2016 [cited 2020 March 1]. Available from: www.anzca.edu.au/ documents/ps08-2015-statement-on-the-assistant-for-the-anaes.pdf
  10. Safety data sheets (SDSs). Available from: www.safeworkaustralia.gov.au/sds
  1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Antimicrobial stewardship in Australian health care [Internet]. Sydney: ACSQHC; 2018 [cited 2020 February 6] Available from: www.safetyandquality. gov.au/sites/default/files/migrated/AMS-Cover- Contents-and-Acknowledgements-Antimicrobial- Stewardship-in-Australian-Health-Care-2018.pdf
  2. Wilcock M, Powell N, Underwood F. Antimicrobial stewardship and the hospital nurse and midwife: How do they perceive their role? Eur J Hosp Pharm 2019;26(2):89–92. DOI: 10.1136/ejhpharm-2017-001312
  3. Olans RN, Olans, RD, DeMaria A Jr. The critical role of the staff nurse in antimicrobial stewardship-unrecognized, but already there. Clin Infect Dis 2016;62(1):84–89.  DOI: 10.1093/cid/civ697
  4. Australian Commission on Safety and Quality in Health Care (ACSQHC). Antimicrobial stewardship clinical care standard [Internet]. Sydney: ACSQHC; 2014 [cited 2020 March 6]. Available from: www.safetyandquality.gov. au/our-work/clinical-care-standards/antimicrobial-stewardship-clinical-care-standard
  5. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACQSHC; 2017. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards
  6. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC; 2019. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  7. Centers for Disease Control and Prevention (CDC). Antibiotic/antimicrobial resistance: Biggest threats [Internet]. Atlanta: CDC; 2019 [cited 2020 February 6]. Available from: www.cdc.gov/drugresistance/biggest_ threats.html
  8. International Council of Nurses (ICN). Position statement: Antimicrobial resistance. [Internet]. Geneva: ICN; 2017 [cited 2020 February 6]. Available from: www.icn.ch/sites/default/files/inline-files/ICN_PS_ Antimicrobial_resistance.pdf
  9. South Australian Expert Advisory Group on Antimicrobial Resistance (SAAGAR) for SA Health. Surgical antimicrobial prophylaxis clinical guideline policy no.: CG269. Version 2. [Internet]. Adelaide: SAAGAR; 2017 [cited 2020 February 6]. Available from: www.sahealth.sa.gov.au/wps/wcm/ connect/6bb523804358edbd883b9ef2cadc00ab/ Surgical+Antimicrobial+Prophylaxis_v2.0_23112017. pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE- 6bb523804358edbd883b9ef2cadc00ab-mMHP6uy
  10. World Health Organization (WHO). Antibiotic resistance [Internet]. Geneva: WHO; 2018 [cited 2020 March 5]. Available from: www.who.int/ antimicrobial-resistance/en/
  11. World Health Organization (WHO). Antimicrobial resistance global report on surveillance [Internet]. Geneva: World Health Organization; 2014 [cited 2020 February 6]. Available from: https://www.who.int/antimicrobial-resistance/publications/surveillancereport/en/
  12. Communicable Diseases Network of Australia. Towards a nationally consistent public health response to multi-drug resistant organisms. A communicable diseases network of Australia discussion paper. [Internet]. Australian Group on Antimicrobial Resistance; 2019 [cited 2020 February 6]. Available from: http://agargroup.org.au/wp-content/uploads/2017/09/July-2017-21.4.2.-CDNA-MRO-discussion-Paper-for-consultation.pdf
  13. Government of the United Kingdom. Tackling drug-resistant infections globally: Final report and recommendations [Internet]. London: Government of UK; 2016 [cited 2020 February 6]. Available from: http://researchbriefings.files.parliament.uk/documents/LLN-2016-0044/LLN-2016-0044.pdf
  14. Mitchell BG, Shaban RZ, MacBeth D, Wood CJ, Russo PL. The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infect Dis Health 2017;22(3):117–128. DOI: 10.1016/j.idh.2017.07.001
  15. Russo PL, Stewardson AJ, Cheng AC, Bucknall T, Mitchell BG. The prevalence of healthcare associated infections among adult inpatients at nineteen large Australian acute-care public hospitals: A point prevalence survey. Antimicrob Resist Infect Control 2019;8(1):114 DOI: 10.1186/s13756-019-0570-y
  16. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: First Australian report on antimicrobial use and resistance in human health [Internet]. Sydney: ACSQHC; 2016 [cited 2020 February 6]. Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/aura-2016-first-australian-report-antimicrobial-use-and-resistance-human-health-summary-report
  17. American Nurses Association (ANA) and Centers for Disease Control and Prevention (CDC). Redefining the antibiotic stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the role of registered nurses in hospital antibiotic stewardship practices. Silver Spring, MD: ANA; 2017
  18. Therapeutic Guidelines Ltd. Antibiotic. North Melbourne: Therapeutic Guidelines Ltd; 2019
  19. Antonioli P, Formaglio A, Gamberoni D, Bertoni L, Perrone P. Stefanati A et al. Hospital discharge in patients at risk of surgical site infection: Antimicrobial stewardship at Ferrara University hospital, Italy. J Prev Med Hyg 2018;59(2):E139–E144
  20. Department of Health. Responding to the threat of antimicrobial resistance: Australia’s first national antimicrobial resistance strategy 2015–2019 [Internet]. Canberra: Department of Health; 2015 [cited 2020 February 6]. Available from: www.amr.gov.au/ resources/national-amr-strategy
  21. European Centre for Disease Prevention and Control. EU guidelines for the prudent use of antimicrobials in human health [Internet]. Brussels: European Commission; 2017 [cited 2020 February 6]. Available from: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52017XC0701(01)
  22. Australian Commission on Safety and Quality in Health Care (ACSQHC). Preventing and controlling healthcare-associated infection standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 20]. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare-associated-infection-standard
  23. Australian Commission on Safety and Quality in Health Care (ACSQHC). Medication safety standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 20]. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard
  24. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2019: Third Australian report on antimicrobial use and resistance in human health [Internet]. Sydney: ACSQHC; 2019 [cited 2020 March 6]. Available from: https://www.safetyandquality.gov.au/sites/default/files/2019-06/AURA-2019-Report.pdf
  25. Association of periOperative Registered Nurses (AORN). AORN guidelines for perioperative practice 2019. Denver, CO: AORN Inc; 2019.
  26. Wood A. Updates to the AORN evidence rating model. AORN J 2019;110(1):5–8. DOI: 10.1002/aorn.12744
  27. Campbell TJ, Decloe M, Gill S, Ho G, McCready J, Powis J. Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use. E Plos One 2017;12(5):e0178434. DOI: 10.1371/journal.pone.0178434
  28. Zukowski CM. Antimicrobial stewardship and patient safety. AORN J 2016;104(4):354–356. DOI: 10.1016/j.aorn.2016.08.002
  29. Edwards R, Drumright L, Holmes A, Kiernan M. Covering more territory to fight resistance: Considering nurses’ role in antimicrobial stewardship. J Infect Prev 2011;12(1):6–10. DOI: 10.1177/1757177410389627
  30. De Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis. Medicine 2017;96(29):e6903. DOI: 10.1097/MD.0000000000006903
  31. Carter EJ, Greendyke WG, Furuya EY, Srinivasan A, Shelley AN, Bothra A et al. Exploring the nurses’ role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists. Am J Infect Control 2018;46(5):492–497. DOI: 10.1016/j.ajic.2017.12.016
  1. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Control of Infection in Healthcare [Internet]. Commonwealth of Australia; 2019 [cited 2020 February 18]. Available from https://nhmrc.govcms. gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  2. Russo PL, Stewardson AJ, Cheng AC, Bucknall T, Mitchell BG. The prevalence of healthcare associated infections among adult inpatients at nineteen large Australian acute-care public hospitals: A point prevalence survey. Antimicrob Resist Infect Control 2019;8(1):114. DOI: 10.1186/s13756-019-0570-y
  3. Owens CD, Stoessel K. Surgical site infections: Epidemiology, microbiology and prevention. J Hosp Infect 2008;70(Suppl 2):3–10. DOI: 10.1016/S0195-6701(08)60017-1
  4. Cooper RA (2013). Surgical site infections: epidemiology and microbiological aspects in trauma and orthopaedic surgery. Int Wound J 2013;10(Suppl 1):3–8. DOI: 10.1111/iwj.12179
  5. MacFie J. Surgical sepsis. Br J Surg 2013;100(9):1119– 1122. DOI: 10.1002/bjs.9155_1
  6. Saito Y, Kobayashi H, Uetera Y, Yasuhara H, Kajiura T, Okubo T. Microbial contamination of surgical instruments used for laparotomy. Am J Infect Control 2014;42(1):43–47.  DOI: 10.1016/j.ajic.2013.06.022
  7. Thompson SM, Middleton M, Farook M, Cameron- Smith A, Bone S, Hassan A. The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery. Ann R Coll Surg Engl 2011;93(8):589– 590. DOI: 10.1308/147870811X13137608455334
  8. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards, Standard 1 Governance for Safety and Quality in Health Service Organisations [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 1]. Available from https://www.safetyandquality.gov.au/our-work/clinical-governance/clinical-governance-standard
  9. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards, Standard 3 Preventing and Controlling Healthcare Associated Infections [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 1]. Available from https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare-associated-infection-standard
  10. Rowley S, Clare S, Macqueen S, Molyneaux R. ANTT v2: An updated practice framework for aseptic technique. Br J Nurs (Intravenous Suppl) 2010;19(5):S5–S11. Available from: https://doi.org/10.12968/bjon.2010.19.Sup1.47079
  11. Von Woedtke T, Kramer A. The limits of sterility assurance. GMS Krankenhhyg Interdiszip 2008;3(3):Doc 19. PMCID: PMC2831250
  12. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 1]. Available from: www.safetyandquality.gov.au/standards/nsqhs-standards
  13. Australian Commission on Safety and Quality in Health Care (ACSQHC). Aseptic technique risk matrix [Internet]. Sydney: ACSQHC; 2018 [cited 2020 March 1]. Available from: www.safetyandquality.gov.au/publications-and-resources/resource-library/nsqhs-standards-aseptic-technique-risk-matrix
  14. Clark RP, DeCalcina-Goff ML. Some aspects of the airborne transmission of infection. J R Soc Interface 2009;6(Suppl 6):S767–S782. DOI: 10.1098/rsif.2009.0236.focus
  15. Standards Australia. AS 3789.3:1994. Textiles for health care facilities and institutions – apparel for operating theatre staff. Canberra: Standards Australia; 1994 [cited 2014 February 18]. Available from: https://www.standards.org.au/standards-catalogue/sa-snz/manufacturing/tx-015/as--3789-dot-3-1994
  16. Harder EE, Gaies MG, Yu S, Donohue JE, Hanauer DA, Goldberg CS et al. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg 2013;146(2):326–333. doi: 10.1016/j.jtcvs.2012.09.062
  17. Bonnevialle N, Geiss L, Cavali L, Ibnoulkhatib A, Verdeil X, Bonnevialle P. Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: Bacteriological comparative analysis. Orthop Traumatol Surg Res 2013;99(6):659–665. DOI: 10.1016/j.otsr.2013.04.004
  18. Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N, Dujardin F. Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: When gloves should be changed. Orthop Traumatol Surg Res 2012;98(4):432–440. DOI: 10.1016/j.otsr.2011.10.015
  19. Alrabaa S. Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment. Am J Infect Control 2013;41(9):850. DOI: 10.1016/j.ajic.2013.03.001
  20. Kovaleva J, Peters FTM, Van der Mei HC, Degener JE. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013;26(2):231–254. DOI: 10.1128/CMR.00085-12
  21. Wixtrom RN, Stutman RL, Burke RM, Mahoney AK, Codner MA. Risk of breast implant bacterial contamination from endogenous breast flora, prevention with nipple shields, and implications for biofilm formation. Aesthet Surg J 2012;32(8):956–963. DOI: 10.1177/1090820X12456841
  22. Adams JS, Korniewicz DM, El-Masri MM. A descriptive study exploring the principles of asepsis techniques among perioperative personnel during surgery. Can Oper Room Nurs J 2011;29(4):6–8,14–6,21–4. 
  23. Yang TY, Henry L, Dellinger M, Yonish K, Emerson B, Seifert PC. The circulating nurse’s role in error recovery in the cardiovascular OR. AORN J 2012;95(6):755–762. DOI:10.1016/j.aorn.2011.09.022.  
  24. Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations. Canberra: Standards Australia; 2014. 
  25. Gandham S, McNicholas M. Maintaining the sterility of the mobile C-arm during intramedullary nailing. Oper Tech Orthop 2014;29(2):99–101. doi: 10.1097/BTO.0b013e318290874f
  26. Rutala WA, Weber DJ. Disinfectants used for environmental disinfection and new room decontamination technology. Am J Infect Control 2013;41(5 Suppl):S36–41. doi: 10.1016/j.ajic.2012.11.006.
  27. Otter JA, Yezli S, Salkeld JAG, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control 2013;41(5 Suppl):S6–S11. DOI: 10.1016/j.ajic.2012.12.004
  28. Friedman Z, Siddiqui N, Mahmoud S, Davies S. Video-assisted structured teaching to improve aseptic technique during neuraxial block. Br J Anaesth 2013;111(3):483–487. DOI: 10.1093/bja/aet062
  29. Parra AP, Menarguez MC, Granda MJP, Torney MJ, Padilla B, Bouza E. A simple educational intervention to decrease incidence of central line-associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI. Infect Control Hosp Epidemiol 2010;31(9):964–967. DOI: 10.1086/655841
  30. Radcliff KE, Rasouli MR, Neusner A, Kepler CK, Albert TJ, Rihn JA et al. Preoperative delay of more than 1 hour increases the risk of surgical site infection. Spine 2013;38(15):1318–1323. DOI: 10.1097/BRS.0b013e31828f1f0b
  31. Singh S, Kumar RK, Sundaram KR, Kanjilal B, Nair P. Improving outcomes and reducing costs by modular training in infection control in a resource-limited setting. Int J Qual Health Care 2012;24(6):641–648. DOI: 10.1093/intqhc/mzs059
  1. Parkes AW, Harper N, Herwadkar A, Pumphrey R. Anaphylaxis to the chlorhexidine component of Instillagel: A case series. Br J Anaesth 2009;102(1):65–68. DOI: 10.1093/bja/aen324
  2. Abdallah C. Perioperative chlorhexidine allergy: Is it serious? J Anaesthesiol Clin Pharmacol 2015;31(2):152– 154. DOI: 10.4103/0970-9185.155140
  3. Therapeutic Goods Administration (TGA). Australian register of therapeutic goods (ARTG) [Internet]. Canberra: TGA; 2019 [cited 2020 February 20]. Available from: www.ebs.tga.gov.au
  4. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 February 20]. Available from: https://nhmrc.govcms. gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  5. Opstrup MS, Jemec GBE, Garvey LH. Chlorhexidine allergy: On the rise and often overlooked. Curr Allergy Asthma Rep 2019;19(5):23. DOI: 10.1007/s11882-019-0858-2
  6. Rutkowski K, Wagner A. Chlorhexidine: A new latex? Eur Urol 2015;68(3):345–347. DOI: 10.1016/j.eururo.2015.04.040
  7. Mertes PM, Ebo DG, Garcez T, Rose M, Sabato V, Takazawa T et al. Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019;123(1):e16–e28. DOI: 10.1016/j.bja.2019.01.027
  8. Rose MA, Garcez T, Savic S, Garvey LH. Chlorhexidine allergy in the perioperative setting: A narrative review. Br J Anaesth 2019;123(1):e95–e103. DOI: 10.1016/j.bja.2019.01.033
  9. Evans D, Jayasekara R, Price K. What is the impact of chlorhexidine use on the incidence of anaphylaxis? Review Team: 2017.
  10. Volcheck GW, Hepner DL. Identification and management of perioperative anaphylaxis. J Allergy Clin Immunol Pract 2019;7(7):2134–2142. DOI: 10.1016/j.jaip.2019.05.033
  11. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACSQHC; 2017. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards
  12. Therapeutic Goods (Charges) Act 1989.
  13. Therapeutic Goods (Medical Devices) Regulations 2002.
  14. Therapeutic Goods Administration (TGA). Therapeutic goods (standard for disinfectants and sanitary products) (TGO 104) order 2019. Canberra: TGA; 2019.
  15. Therapeutic Goods Administration (TGA). Australian register of therapeutic goods. Canberra: TGA; 2019.
  16. Wood A. Updates to the AORN evidence rating model. AORN J 2019;110(1):5–8. DOI: 10.1002/aorn.12744
  17. Association of periOperative Registered Nurses (AORN). AORN guidelines for perioperative practice 2019. Denver: AORN; 2019.
  18. Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R et al. Management of suspected immediate perioperative allergic reactions: An international overview and consensus recommendations. Br J Anaesth 2019;123(1):e50–e64. DOI: 10.1016/j.bja.2019.04.044
  19. Dardeer A, Shallik N. Perioperative anaphylaxis: A new visit to an old topic. Trends Anaesth Crit Care 2019;26– 27(1–10). Available from: https://doi.org/10.1016/j.tacc.2019.04.005
  20. Moka E, Argyra E, Siafaka I, Vadalouca A. Chlorhexidine: Hypersensitivity and anaphylactic reactions in the perioperative setting. J Anaesthesiol Clin Pharmacol 2015;31(2):145–148. DOI: 10.4103/0970-9185.155138
  21. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines on the perioperative management of patients with suspected or proven hypersensitivity to chlorhexidine. Melbourne: ANZCA; 2016.
  22. Scolaro RJ, Crilly HM, Maycock EJ, McAleer PT, Nicholls KA, Rose MA et al. Australian and New Zealand anaesthetic allergy group perioperative anaphylaxis investigation guidelines. Anaesth Intensive Care 2017;45(5):543–555. DOI: 10.1177/0310057X1704500504
  23. Australasian Society of Clinical Immunology and Allergy (ASCIA) and Australia and New Zealand Anaesthetic Allergy Group (ANZAAG). Chlorhexidine allergy [Internet]. Brookvale NSW: ASCIA; 2019 [updated 2019 April, cited 2020 February 20]. Available from: www.allergy.org.au/patients/drug-allergy/ chlorhexidine-allergy
  24. Teixeira de Abreu AP, Ribeiro de Oliveira LR, Teixeira de Abreu AF, Ribeiro de Oliveira E, Santos de Melo Ireno M, Aarestrup FM et al. Perioperative anaphylaxis to chlorhexidine during surgery and septoplasty. Case Rep Otolaryngol 2017;2017:9605804. DOI: 10.1155/2017/9605804
  25. Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: Potential, limitations, and perspectives. Br J Anaesth 2019;123(1):e117–e125. DOI: 10.1016/j.bja.2019.01.002
  26. Ebo DG, Van Gasse AL, Decuyper, II, Uyttebroek A, Sermeus LA, Elst J et al. Acute management, diagnosis, and follow-up of suspected perioperative hypersensitivity reactions in Flanders 2001–2018. J Allergy Clin Immunol Pract 2019;7(7):2194–2204.e2197. DOI: 10.1016/j.jaip.2019.02.031
  27. Provinciael S, Saldien V, Hans G, Vercauteren M. Perioperative allergy and anaphylaxis in children: A review. Acta Anaesthesiologica Belgica 2018;69(1):13–24.
  1. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 3]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACSQHC; 2017.
  3. Therapeutic Goods (Charges) Act 1989.
  4. Therapeutic Goods (Medical Devices) Regulations 2002.
  5. Therapeutic Goods Administration (TGA). Therapeutic goods (standard for disinfectants and sanitary products) (TGO 104) order 2019. Canberra: TGA; 2019.
  6. Therapeutic Goods Administration (TGA). Guidelines for the evaluation of sterilants and disinfectants [Internet]. Canberra: TGA;1998 [cited 2020 February 5]. Available from: www.tga.gov.au/publication/guidelines-evaluation-sterilants-and-disinfectants
  7. Therapeutic Goods Administration (TGA). Australian register of therapeutic goods. Canberra: TGA; 2019.
  8. Phillips NH. Berry and Kohn’s Operating Room Technique. 11th ed. St. Louis: Mosby; 2006. 
  9. Rothrock JC. Alexander’s Care of the Patient in Surgery. 15th ed. St Louis: Mosby; 2014. 
  10. Australian Commission on Safety and Quality in Health Care (ACSQHC). Healthcare associated infection [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 3]. Available from: www.safetyandquality.gov.au/our-work/ healthcare-associated-infection
  11. Nelson J, Bivans A, Shinnn A, Wanzer L, Kasper C. Microbial flora on operating room telephones. AORN J 2006;83(3)607-611,613-617,619-620. DOI: 10.1016/s0001-2092(06)60190-7
  12. Licensing Standards and Review Unit. Licensing standards for the arrangements for management, staffing and equipment, Private Hospitals. East Perth: Department of Health; 2006, pp. 7-17.
  1. Visvanathan AG, Gibb AP, Brady R. Increasing clinical presence of mobile communication technology: Avoiding the pitfalls. Telemed J E Health 2011;17(8):656– 661. DOI: 10.1089/tmj.2011.0018
  2. Standing Committee on Law and Justice. Remedies for the serious invasion of privacy in New South Wales. Sydney: Standing Committee on Law and Justice; 2016.  
  3. Australian Medical Association (AMA). Clinical images and the use of personal mobile devices: A guide for medical students and doctors [Internet]. Canberra: AMA; 2014. 
  4. Calianno CA, Martin-Boyan A. When is it appropriate to photograph a patient’s wound? Adv Skin Wound Care 2006;19(6):304–306. DOI: 10.1097/00129334-200607000-00008
  5. Lakdawala NFK, Fontanella D, Grant-Kels JM. Ethical considerations in dermatologic photography. Clin Dermatol 2012;30(5):486–491. DOI: 10.1016/j.clindermatol.2011.06.017
  6. Jonas M, Malpas P, Kersey K, Merry A, Bagg W. Applying ethical and legal principles to new technology: The University of Auckland Faculty of Medical and Health Sciences’ policy ‘Taking and sharing images of patients’. NZ Med J 2017;130(1449):30–38. 
  7. Adeyemo WL, Mofikoya BO, Akadiri OA, James O, Fashina AA. Acceptance and perception of Nigerian patients to medical photography. Dev World Bioeth 2013;13(3):105–110. DOI: 10.1111/j.1471-8847.2012.00328.x
  8. Mahar PD, Foley PA, Scheed-Finck A, Baker CS. Legal considerations of consent and privacy in the context of clinical photography in Australian medical practice. Med J Aust 2013;198(1):48–49. DOI: 10.5694/mja12.11086
  9. Palacios-Gonzalez C. The ethics of clinical photography and social media. Med Health Care Philos 2015;18(1):63– 70. DOI: 10.1007/s11019-014-9580-y
  10. Stevenson PF, Finnane RA, Soyer HP. Teledermatology and clinical photography: Safeguarding patient privacy and mitigating medico-legal risk. Med J Aust 2016;204(5):198–200e1. DOI: 10.5694/mja15.00996
  11. Turnbull AM, Elmsley ES. Video recording of ophthalmic surgery – ethical and legal considerations. Surv Ophthalmol 2014;59(5):553–558. DOI: 10.1016/j.survophthal.2014.01.006
  12. Lau CK, Schumacher HH, Irwin MS. Patients’ perception of medical photography. J Plast Reconstr Aesthet Surg 2010;63(6):e507–511. DOI: 10.1016/j.bjps.2009.11.005
  13. Engelstad ME, McClellan M, Jacko JA, Melton GB. Deidentification of facial images using composites. J Oral Maxillofac Surg 2011;69(12):3026–3031. DOI: 10.1016/j.joms.2011.01.011
  14. Harting MT, DeWees JM, Khirallah RT. Medical photography: Current technology, evolving issues and legal perspectives. Int J Clin Pract 2015;69(4):401–409. DOI: 10.1111/ijcp.12627
  15. Privacy Act 1988. 
  16. NSW Health. Privacy manual for health information [Internet]. Sydney: NSW Health; 2015 [cited 2020 March 3]. Available from: www.health.nsw.gov.au/ policies/manuals/Documents/privacy-manual-for-health-information.pdf  
  17. Medicare Australia, Submission PR 534, 21 December 2007 in Australian Government. Australian Law Reform Commission (ALRC). For your information: Australian privacy law and practice (ALRC report 108). ALRC: Canberra; 2008 [cited 2020 March 3]. Available from: www.alrc.gov.au/publications/report-108  
  18. Office of the Australian Information Commissioner (OAIC). Privacy fact sheet 17: Australian privacy principles [Internet]. Canberra: OAIC; 2019 [cited 2019 November 12]. Available from: www.oaic.gov.au/ individuals/privacy-fact-sheets/general/privacy-fact-sheet-17-australian-privacy-principles
  19. Quail MT. Technology in health care: Forensic implications. Crit Care Nurs Q 2015;38(1):49–80. DOI: 10.1097/CNQ.0000000000000049
  20. Petrini C. Ethical issues in videorecording patients lacking capacity to consent. Ann Ist Super Sanita 2011;47(3):247–252. DOI: 10.4415/ANN_11_03_02
  21. Archibald DJ, Carlson ML, Friedman O. Pitfalls of nonstandardized photography. Facial Plast Surg Clin North Am 2010;18(2):253–266. DOI: 10.1016/j.fsc.2010.01.005
  22. Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses [Internet]. Canberra: NMBA; 2018 [cited 2019 November 12]. Available from: www. nursingmidwiferyboard.gov.au/Codes-Guidelines- Statements/Professional-standards.aspx 
  23. Nursing and Midwifery Board of Australia (NMBA). Code of conduct for midwives [Internet]. Canberra: NMBA; 2018 [cited 2019 November 12]. Available from: www. nursingmidwiferyboard.gov.au/Codes-Guidelines- Statements/Professional-standards.aspx
  24. Nursing and Midwifery Board of Australia (NMBA). Registered nurse standards for practice [Internet]. Canberra: NMBA; 2016 [cited 2018 February 15]. Available from: www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Professional-standards. aspx.
  25. Nursing and Midwifery Board of Australia (NMBA). Enrolled nurse standards for practice [Internet]. Canberra: NMBA; 2016 [cited 2019 November 12]. Available from: www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Professional-standards.aspx 
  26. Nursing and Midwifery Board of Australia (NMBA). Nurse practitioner standards for practice [Internet]. Canberra: NMBA; 2014 [cited 2019 November 12]. Available from: www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Professional-standards.aspx 
  27. Nursing and Midwifery Board of Australia (NMBA). Midwifery standards for practice [Internet]. Canberra: NMBA; 2006 [cited 2019 November 12]. Available from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines- Statements/Professional-standards.aspx
  28. Fehring KA, De Martino I, McLawhorn AS, Sculco PK. Social media: Physicians-to-physicians education and communication. Curr Rev Musculoskelet Med 2017;10(2):275–277. DOI: 10.1007/s12178-017-9411-x
  29. Thomairy NA, Mummaneni M, Alsalamah S, Moussa N, Coustasse A. Use of smartphones in hospitals. Health Care Manage 2015;34(4):297–307. DOI: 10.1097/HCM.0000000000000080
  30. Australian Health Practitioner Regulation Agency (AHPRA). Social media policy [Internet]. Melbourne: AHPRA; 2014 [updated 2019 November 11, cited 2020 March 3]. Available from www.nursingmidwiferyboard. gov.au/News/2019-11-11-Social-media-guide.aspx  
  31. Crane GM, Gardner JM. Pathology image-sharing on social media: Recommendations for protecting privacy while motivating education. AMA J Ethics 2016;18(8):817–825.DOI: 10.1001/journalofethics.2016.18.8.stas1-1608
  32.  Health Practitioner Regulation National Law Act 2009. 
  33. Ellaway R, Cameron H, Ross M with contributions from Laurie G, Maxwell M and Pratt R. Clinical recordings for academic non-clinical settings. CHERRI Project Report [Internet]. Edinburgh, UK: CHERRI Project 2006 [cited 2018 March 20]. Available from: www.archive.mvm.ed.ac. uk/cherri-pie/
  34. General Medical Council (GMC). Making and using visual and audio recordings of patients. London: GMC; 2013. 
  35. Payne KF, Tahim A, Goodson AM, Delaney M. Fan K. A review of current clinical photography guidelines in relation to smartphone publishing of medical images. J Vis Commun Med 2012;35 (4):188–92. DOI:10.3109/174530 54.2012.747174. 
  36. Taylor K, Mayell A, VanDenberg S, Blanchard N, Parshuram CS. Prevalence and indications for video recording in the health care setting in North American and British paediatric hospitals. Paediatr Child Health 2011;16(7):e57–e60. DOI: 10.1093/pch/16.7.e57
  37. Berle I. Clinical photography and patient rights: The need for orthopraxy. J Med Ethics 2008;34(2):89–92. DOI: 10.1136/jme.2006.019166
  38. Department of Health (UK). Good practice in consent implementation guide: Consent to examination or treatment. London: Department of Health (UK); 2001. 
  39. Caires B, Lopes M, Okuno M, Vancine-Campanhora C, Batista R. Knowledge of healthcare professionals about rights of patient’s images. Einstein 2015;13(2):255–259. DOI: 10.1590/S1679-45082015AO3207
  40. Privacy and Personal Information Protection Act 1998 (NSW) No. 133. 
  41. Gonzalez DR. An open source toolkit for medical imaging de-identification. Eur Radiol 2010;20(8):1896– 1904. DOI: 10.1007/s00330-010-1745-3
  42. Moore SM, Maffitt DR, Smith KE, Kirby JS, Clark KW, Freymann JB et al. De-identification of medical images with retention of scientific research value. Radiographics 2015;35(3):727–735. DOI: 10.1148/rg.2015140244
  43. Allen KG, Eleftheriou P, Ferguson J. A thousand words in the palm of your hand: Management of clinical photography on personal mobile devices. Med J Aust 2016;205(11):499–500. DOI: 10.5694/mja16.00520
  44. Kornhaber RB, Betihavas V, Baber RJ. Ethical implications of digital images for teaching and learning purposes: An integrative review. J Multidiscip Healthc 2015;8:299–305. DOI: 10.2147/JMDH.S84488
  45. Burns K, Belton S. Clinicians and their cameras: Policy, ethics and practice in an Australian tertiary hospital. Aust Health Rev 2013;37(4):437–441. DOI: 10.1071/AH12039
  46. Clover AJ, Fitzpatrick E, Healy C. Analysis of methods of providing anonymity in facial photographs: A randomised controlled study. Ir Med J 2010;103(8):243– 245. 
  47. Dysmorphology Subcommittee of the Clinical Practice Committee, American College of Medical Genetics, Cunniff C, Byrne JLB, Hudgins LM, Moeschler JB et al. Informed consent for medical photographs. Genet Med 2000;2(6):353–355. DOI: 10.1097/00125817-200011000-00010
  48. Janke T. Pathways & Protocols: A Filmmaker’s Guide to Working with Indigenous People, Culture and Concepts. Ultimo, NSW: Screen Australia; 2009.
  49. Wehbe-Alamah H. Bridging generic and professional care practices for Muslim patients through use of Leininger’s culture care modes. Contemp Nurse 2008;28(1–2): 83–97. DOI: 10.5172/conu.673.28.1-2.83
  50. Balmer CG, Griffiths F, Dunn J. A review of the issues and challenges involved in using participant-produced photographs in nursing research. J Adv Nurs 2015;71(7):1726–1737. DOI: 10.1111/jan.12627
  51. Koch CA, Larrabee W. Patient privacy, photographs and publication. JAMA Facial Plast Surg 2013;15(5):335–336. DOI: 10.1001/jamafacial.2013.1411
  52. Archer AC, Campbell L, Crocker J, Dinh AK, Kogan E, Miller J et al. Managing nontext media in healthcare practices. J AHIMA 2011;82(11):54–58. 
  53. Prigoff JG, Sherwin M, Devinio C. Ethical recommendations for video recording in the operating room. Ann Surg 2016;264(1):34–35. DOI: 10.1097/SLA.0000000000001652
  54. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards (2nd ed.) Standard 1: Clinical governance. Sydney: ACSQHC; 2017 [cited 2020 March 3]. Available from: www.safetyandquality.gov.au/our-work/ clinical-governance/clinical-governance-standard
  55. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards (2nd ed.) Standard 7: Communicating for safety. Sydney: ACSQHC; 2017 [cited 2020 March 3]. Available from: www.safetyandquality. gov.au/standards/nsqhs-standards/communicating-safety-standard
  56. Althubaiti G, Buntic R, Brooks D. The utility of multimedia in the diagnosis and management of acute and subacute problems in hand surgery. Ann Plast Surg 2012;68(4):389–390. DOI: 10.1097/SAP.0b013e318242e114
  57. Detterbeck AM. Electronic transfer of sensitive patient data. Int J Comput Dent 2015;18(1):45–57. 
  58. Barber H. Smartphone and mobile phone security for the clinician. Br J Hosp Med 2016;77(8):467–470. DOI: 10.12968/hmed.2016.77.8.467
  59. Matharu J, Hale B, Anmar M, Brennan PA. Short message service (SMS) texting as a method of communication during on call: Prevalence and experience of medical staff in a large acute NHS Trust in the UK. Br J Oral Maxillofac Surg 2016;54(8):863–867. DOI: 10.1016/j.bjoms.2016.05.034
  1. Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations. Canberra: Standards Australia; 2014. 
  2. Standards Australia. AS ISO 8828:2015 Implants for surgery - Guidance on care and handling of orthopaedic implants. Sydney: Standards Australia; 2015. 
  3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Healthcare Associated Infection [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 3]. Available from www.safetyandquality.gov. au/standards/nsqhs-standards/preventing-and-controlling- healthcare-associated-infection-standard
  4. Standards Australia. AS 3816:2018 Management of clinical and related wastes. Sydney: Standards Australia; 2018. 
  5. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 February 20]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  6. Lawrence A. Presumed consent organ donation under Australian law. Paper prepared for the Australian Medical Association and the Australian National University law internship program. 2004.
  7. Dewer S, Boddington P. Returning to the Alder Hey report and its reporting: Addressing confusions and improving inquiries. J Med Ethics 2004;30(5):463–469. DOI: 10.1136/jme.2002.002774
  8. Human Tissue and Transplant Act 1982 (WA).
  9. Environmental Protection Act 1994 (Qld).
  10. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research: Chapter 2.2 General requirements for consent [Internet]. Canberra: NHMRC; 2018 [updated 2018; cited 2019 November 12]. Available from: www.nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007- updated-2018
  1. Braaf S, Riley R, Manias E. Failures in communication through documents and documentation across the perioperative pathway. J Clin Nurs 2015;24(13–14):1874– 1884. [VA] DOI: 10.1111/jocn.12809
  2. Bigony L. Charting the course with the PNDS. OR Nurse. 2010;4(6):15–21. [VC]
  3. New South Wales Nurses and Midwives’ Association. Guidelines on documentation and electronic documentation [Internet]. Sydney: NSW Nurses and Midwives’ Association; 2010 [cited 2020 March 3]. Available from: www.nswnma.asn.au/wp-content/ uploads/2013/07/Guidelines-on-Electronic- Documentation-and-Documentation.pdf. [IVA]
  4. Echhard MB, Martin D. Roles of the perioperative nurse and informaticist and implications for practice, education and administration. Perioperative Nursing Clinics 7 2012:267–282. [VA] doi:10.1016/j.cpen.2012.02.003
  5. Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med (Lond) 2017;78(2):104–107. [IIIA] DOI: 10.12968/hmed.2017.78.2.104
  6. Pirie S. Documentation and record keeping. J Perioper Pract 2011;21(1):22–27. [VA] DOI: 10.1177/175045891102100103
  7. Ridout J, Aucoin J, Browning A, Piedra K, Weeks S. Does perioperative documentation transfer reliably? Comput Inform Nurs 2014;32(1):37–42. [VA] DOI: 10.1097/CIN.0000000000000017
  8. Staunton P, Chiarella M. Nursing and the law. 6th ed. Sydney: Churchill Livingstone Elsevier; 2008. [VA]
  9. Adeleke IT, Adekanye AO, Onawola KA, Okuku AG, Adefemi SA, Erinle SA et al. Data quality assessment in healthcare: A 365-day chart review of inpatients’ health records at a Nigerian tertiary hospital. J Am Med Inform Assoc 2012;19(6):1039–1042. [IIIA] DOI: 10.1097/CIN.0000000000000017
  10. Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway: A literature review. Int J Nurs Stud 2011;48(8):1024–1038. [VA] DOI: 10.1016/j.ijnurstu.2011.05.009
  11. St Jacques P, Rothman B. Enhancing point of care vigilance using computers. Anesthesiol Clin 2011;29(3):505–519. [VB] DOI: 10.1016/j.anclin.2011.05.008
  12. Phillips NF. Berry and Kohn’s Operating Room Technique. 13th ed. St. Louis: Mosby; 2017. [VA]
  13. Stallard J, Bhat W, Teoh V, Smith IM. Improving patient care in plastic surgery: With structured documentation. J Plast Reconstr Aesthet Surg 2015;68(5):749–750. [IIIV] DOI: 10.1016/j.bjps.2015.01.003
  14. New South Wales Health. Health care records – documentation and management [Internet]. Sydney: New South Wales Health; 2012 [cited 2020 March 3]. Available from: www1.health.nsw.gov.au/pds/ ActivePDSDocuments/PD2012_069.pdf. [IVA]
  15. Crosson JA. Keeping patients safe: The importance of collaboration. AORN J 2015;101(2):279–281. [VA] DOI: 10.1016/j.aorn.2014.11.006
  16. Tiusanen TS, Junttila K, Leinonen T, Salantera S. The validation of AORN recommended practices in Finnish perioperative nursing documentation. AORN J 2010;91(2):236–247. [IIIB] DOI: 10.1016/j.aorn.2009.06.027
  17. Coates T. The view from the operating table. J Perioper Pract. 2014;24(1–2):6. [VB] DOI: 10.1177/1750458916024001-201
  18. Cartwright SMI, Edney LA. Ambulatory perianesthesia electronic documentation – a two-part series. Part 1: From paper to point and click. J Perianesth Nurs 2012;27(4):267–270. [VB] DOI: 10.1016/j.jopan.2012.05.008
  19. The Joint Commission. Sentinel event data: Root causes by event type 2004–2015 [Internet]. Chicago: The Joint Commission; 2016 [cited 2019 January]. Formerly available from: www.tsigconsulting.com/ tolcam/wp-content/uploads/2015/04/TJC-Sentinel- Event-Root_ Causes_by_Event_Type_2004-2014.pdf. [VA]
  20. De Marinis MG, Piredda M, Pascarella MC, Vincenzi B, Spiga F, Tartaglini D et al. ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. J Clin Nurs 2010;19(11–12):1544–1552. [VC] DOI: 10.1111/j.1365-2702.2009.03012.x
  21. Australian Commission on Safety and Quality in Health Care (ACSQHC). Communication for safety standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 3].Available from: www.safetyandquality.gov.au/ standards/nsqhs-standards/communicating-safety-standard. #Vol2
  22. Fencl JL. Guideline implementation: Patient information management. AORN J 2016;104(6):566–577. [VA] DOI: 10.1016/j.aorn.2016.09.020
  23. Ghani Y, Thakrar R, Kosuge D, Bates P. ‘Smart’ electronic operation notes in surgery: An innovative way to improve patient care. Int J Surg 2014;12(5):30– 32. [VA] DOI: 10.1016/j.ijsu.2013.10.017
  24. Melton GB, Wang Y, Arsoniadis E, Pakhomov SV, Adam TJ, Kwaan MR et al. Analyzing operative note structure in development of a section header resource. Stud Health Technol Inform 2015;216:821–826. [IIIA] PMCID: PMC4781788
  25. Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses [Internet]. Canberra: NMBA; 2018 [cited 2019 January]. Available from: www.nursingmidwiferyboard.gov.au/Codes- Guidelines-Statements/Professional-standards.aspx. [IVA]
  26. Australian College of Perioperative Nurses (ACORN). Standards for Perioperative Nursing in Australia. 15th ed. Adelaide, South Australia: ACORN; 2018. [IVB]
  27. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards [Internet]. Sydney: ACSQHC; 2012 [cited 2020 March 18]. Available from: www. safetyandquality.gov.au/standards/nsqhs-standards.  [IVB]  
  28. Arnold P. Rising with accurate documentation to shine in the justice system: A nurse’s experience. ACORN J 2015;28(2):16–19. [VA]
  29. The Association of periOperative Registered Nurses (AORN). Guidelines at a glance: Information management. AORN J 2017;106(3):272–274. [IV]
  30. Nursing and Midwifery Board of Australia (NMBA) [Internet]. Registration standards 2017 [cited 2019 January]. Available from: www.nursingmidwiferyboard. gov.au/Registration-Standards.aspx. [NA]
  31. Hoffmann T, Bennett S, Del Mar C. Evidence-based practice across the health professions. 3rd ed. Chatswood NSW: Elsevier Australia; 2017. [VA]
  32. Sondergaard SF, Lorentzen V, Sorensen EE, Frederiksen K. The documentation practice of perioperative nurses: A literature review. J Clin Nurs 2017;26(13–14):1757–1769. [VA] DOI: 10.1111/jocn.13445
  33. Shaw T, Hines M, Kielly-Carroll C. Impact of digital health on the safety and quality of health care [Internet]. Sydney: Australian Commission on Safety and Quality in Health Care; 2017 [cited 2019 January]. Available from: www.safetyandquality.gov.au// publications/the-impact-of-digital-health-on-safety-and-quality-of-healthcare/. [IVC]
  34. Furukawa MF, Raghu TS, Shao BB. Electronic medical records and cost efficiency in hospital medical-surgical units. Inquiry. 2010;47(2):110–123. [VA] DOI: 10.5034/inquiryjrnl_47.02.110
  35. Golob JF Jr, Como JJ, Claridge JA. The painful truth: The documentation burden of a trauma surgeon. J Trauma Acute Care Surg 2016;80(5):742–747. [IIIB] DOI: 10.1097/TA.0000000000000986
  36. Stanton C. Connections: Managing health information. AORN J 2011;94(2):C1–C9. [VA] https://doi.org/10.1016/S0001-2092(11)00680-6
  37. Clarke JR. Quarterly update in wrong-site surgery: Electronic records can help prevent harm but are not harmless. Pennsylvania Patient Safety Advisory 2014;11(4):172–175. [VB]
  38. Baier AW, Snyder DJ, Leahy IC, Patak LS, Brustowicz RM. A shared opportunity for improving electronic medical record data. Anesth Analg 2017;125(3):952–957. [IIIA] DOI: 10.1213/ANE.0000000000002134
  39. Rebello E, Kee S, Kowalski A, Harun N, Guindani M, Goravanchi F. Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment. Health Informatics J. 2016;22(4):1055–1062. [VIII] DOI: 10.1177/1460458215608901
  40. Sondergaard S, Lorentzen V, Sorensen EE, Frederikson K. Danish perioperative nurses’ documentation: A complex multifaceted practice connected with unit culture and nursing leadership. AORN J 2017;106(1):31– 41. [VC] DOI: 10.1016/j.aorn.2017.05.003
  41. Beach MJ, Sions JA. Surviving OR computerization. AORN J 2011;93(2):226–241. [VA] DOI: 10.1016/j.aorn.2010.05.031
  42. Sanders DS, Read-Brown S, Tu DC, Lambert WE, Choi D, Almario BM et al. Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing. JAMA Ophthalmol 2014;132(5):586–592. [VA] DOI: 10.1001/jamaophthalmol.2013.8196
  43. Sweeney P. The effects of information technology on perioperative nursing. AORN J 2010;92(5):528–540. [VC] DOI: 10.1016/j.aorn.2010.02.016
  44. Australian and New Zealand College of Anaesthetists (ANZCA). The anaesthetic record: Recommendations on the recording of an episode of anaesthesia care [Interne]. Melbourne: ANZCA; 2006 [cited 2019 January]. Formerly available from: www.anzca.edu.au/documents/ps06- 2006-the-anaesthesia-record-recommendations-o. pdf. [IVB] Replaced by PS06 Guideline on the Anaesthesia Record (Pilot)
  1. Spruce L, Braswell ML. Implementing AORN recommended practices for electrosurgery. AORN J 2012;95(3):373–387. DOI: 10.1016/j.aorn.2011.12.018
  2. Rey JF, Beilenhoff U, Neumann CS, Dumonceau JM. European Society of Gastrointestinal Endoscopy (ESGE) guideline: The use of electrosurgical units. Endoscopy 2010;42(9):764–772. DOI: 10.1055/s-0030-1255594
  3. Association of Surgical Technologists (AST). AST standards for practice for use of electrosurgery. Denver: AST; 2012 [cited 2020 March 3]. Available from: www.ast.org/uploadedFiles/MainSite/Content/ AboutUs/Standard%20Electrosurgery.pdf. 
  4. Gallagher K, Dhinsa B, Miles J. Electrosurgery. Surgery 2010;29(2):70–72. https://doi.org/10.1016/j.mpsur.2010.11.009 
  5. Potty A, Khan W, Tailor H. Diathermy in perioperative practice. J Periop Pract 2010;20(11):402–405. DOI: 10.1177/175045891002001103
  6. Bifulco P, Massa R, Cesarelli M, Romano M, Fratini A, Gargiulo G et al. Investigating the role of capacitive coupling between the operating table and the return electrode of an electrosurgery unit in the modification of the current density distribution within the patients’ body. Biomed Eng Online 2013;12(80):1–12. DOI:10.1186/1475-925X-12-80. 
  7. Emergency Care Research Institute (ECRI). Electrosurgical safety. Conducting a safety audit. Health Devices 2005;34(12):414–420. PMID: 16483127
  8. Brill AI. Electrosurgery: Principles and practices to reduce risk and maximise efficacy. Obstet Gynecol Clin North Am 2011;38(4):687–702. DOI: 10.1016/j.ogc.2011.09.005
  9. Covidien. Principles of electrosurgery [cited 2020 March 3]. Boulder: Covidien; 2008. Available from: www.asit.org/assets/documents/Prinicpalsin electrosurgery.pdf. 
  10. Steelman V, Graling P. Top ten patient safety issues: What more can we do? AORN J 2013;97(6):679–701. DOI: 10.1016/j.aorn.2013.04.012
  11. La Chapelle CF, Bemelman WA, Bongers MY, Van Barneveld TA, Jansen FW. A multidisciplinary evidence-based guideline for minimally invasive surgery: Part 2 – Laparoscopic port instruments, trocar site closure, and electrosurgical techniques. Gynecol Surg 2013;10(1):11– 23. https://doi.org/10.1007/s10397-012-0776-y 
  12. Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS 2012;16(1):130–139. DOI: 10.4293/108680812X13291597716348
  13. Sobolewski CJ. Electrosurgery the newest energy-based devices. Contemporary OB/GYN. 2013 Oct 1;58(10):T13. 
  14. Emergency Care Research Institute (ECRI). Evaluation Megadyne mega 2000 return electrode. Health Devices 2000;29(12):445–460. 
  15. Voutslath M, Bickakjian C, Pelosi F, Blum D, Johnson T, Farrehi P. Electrosurgery and implantable electronic devices: Review and implications for office-based procedures. Dermatol Surg 2011;37(7):889–899. DOI: 10.1111/j.1524-4725.2011.02006.x
  16. Montero PN, Robinson, TN, Weaver JS, Stiegmann GV. Insulation failure in laparoscopic instruments. Surg Endosc 2010;24(2):462–465. DOI: 10.1007/s00464-009-0601-5
  17. National Institute for Health and Clinical Excellence (NICE). Mega soft patient return electrode for use during monopolar electrosurgery NICE. Medical Technology Guidance 11. London: NICE; 2012. 
  18. Ethicon Endosurgery. Ultracision harmonic scalpel: Generator 300 system service manual. Cincinatti: Ethicon Endosurgery; n.d. 
  19. King C. Clinical endoscopy – Endoscopic electrosurgery – An overview. Gastrointestinal Nurs 2011;9(4):28–33. https://doi.org/10.12968/gasn.2011.9.4.28
  20. Megadyne. About Megadyne [Internet]. Salt Lake City: Megadyne; 2013 [cited 2020 March 3]. Available from: www.jnjmedicaldevices.com/en-US/product-family/ energy-sealing-dissecting?utm_campaign=ethicon-altdomain-redirect&utm_source=megadyne.com&utm_ medium=referral. 
  21. Marsh A. Pacemakers: Some of the risks and complications you are not warned about. J Periop Pract 2008;18(10):443–448. DOI: 10.1177/175045890801801004
  22. Yazdani A, Krause H. Laparoscopic instrument insulation failure: The hidden hazard. J Minim Invasive Gynecol 2013;14(2):228–232. (C)  DOI: 10.1016/j.jmig.2006.10.009
  23. Nursing and Midwifery Board of Australia (NMBA). Registered nurse standards [Internet]. Canberra: NMBA; 2016 [cited 2020 March 3]. Available from: www.nursingmidwiferyboard. gov.au/Codes-Guidelines- Statements/Professional-standards.aspx. 
  1. Wormer BA, Augenstein Townend W, Cheeseman CR. Guidelines for the evaluation and assessment of the sustainable use of resources and of wastes management at healthcare facilities. Waste Manag Res 2005;23(5):398–408. DOI: 10.1177/0734242X05057764
  2. Tudor T, Barr S, Gilg A. Strategies for improving recycling behaviour within the Cornwall National Health Service in the UK. Waste Manag Res 2007;25(6):510–516.  DOI: 10.1177/0734242X07082030
  3. VA, Carpenter CL, Burton PV, Yokeley WT, Prabhu AS et al. The green operating room: Simple changes to reduce cost and our carbon footprint. Am Surg 2013;79(7):666–671. 
  4. World Health Organization. Safe management of wastes from healthcare activities 2nd ed. [Internet]. Geneva: World Health Organization; 2014 [cited 2020 March 03]. Available from: www.who.int/iris/ bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1. 
  5. Jang J-C, Lee C, Yoon O-S, Kim H. Medical waste management in Korea. J Environ Manage 2006;80(2):107–115. DOI: 10.1016/j.jenvman.2005.08.018
  6. Kagoma Y, Stall N, Rubinstein E, Naudie D. People, planet and profits: The case for greening operating rooms. CMAJ 2012;184(17):1905–1911 DOI: 10.1503/cmaj.112139
  7. Kaplan S, Sadler B, Little K, Franz C, Orris P. Can sustainable hospitals help bend the health care cost curve? Issue Brief (Commonw Fund) 2012;29:1–14. 
  8. Lee RJ, Mears SC. Greening of orthopedic surgery. Orthopedics 2012;35(6):e940–944. DOI: 10.3928/01477447-20120525-39
  9. Lee RJ, Mears SC. Reducing and recycling in joint arthroplasty. J Arthroplasty 2012;27(10):1757–1760. DOI: 10.1016/j.arth.2012.04.020
  10. Lee BK, Ellenbecker MJ, Moure-Eraso R. Alternatives for treatment and disposal of regulated medical wastes. Waste Manage 2004;24(2):143–151. DOI: 10.1016/j.wasman.2003.10.008
  11. Sattler B. The greening of health care: Environmental policy and advocacy in the health care industry. Policy Politics Nurs Pract 2003;4(6):6–13 https://doi.org/10.1177/1527154402239449 
  12. Ciplak N, Barton JR. A system dynamics approach for healthcare waste management: A case study in Istanbul metropolitan city, Turkey. Waste Manag Res 2012;30(6):576–586. https://doi.org/10.1177/0734242X12443405 
  13. Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg 2011;146(2):131–136. DOI: 10.1001/archsurg.2010.343
  14. Reale E. Nurses key to success of waste segregation program. Aust Nurs J 2009;17(3):7. 
  15. Riedel L. Environmental and financial impact of a hospital recycling program. AANA J 2011;79(4):S8–S14. 
  16. Stonemetz J, Pham JC, Necochea AJ, McGready J, Hody RE, Martinez EA. Reduction of regulated medical waste using lean sigma results in financial gains for hospital. Anesthesiol Clin 2011;29(1):145–152. DOI: 10.1016/j.anclin.2010.11.007
  17. Laustsen G. Reduce–recycle–reuse: Guidelines for promoting perioperative waste management. AORN J 2007;85(4):717–728. DOI: 10.1016/S0001-2092(07)60146-X
  18. Laustsen G. Greening in healthcare. Nurse Manage 2010;41(11):26–31. DOI: 10.1097/01.NUMA.0000389012.82998.5d
  19. Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J 2010;91(6):711–721. DOI: 10.1016/j.aorn.2009.12.029
  20. Practice Greenhealth. Greening the OR; Guidance documents. Washington DC: Practice Greenhealth; 2011–2013. 
  21. Southorn T, Norrish AR, Gardner K, Baxandall R. Reducing the carbon footprint of the operating theatre: A multicentre quality improvement program. J Perioper Pract 2013;23(6)144–146. DOI: 10.1177/175045891302300605
  22. Penn E, Yasso SF, Wei JL. Reducing disposable equipment waste for tonsillectomies and adenotonsillectomy cases. Otolaryngol Head Neck Surg 2012;147(4):615–618. DOI: 10.1177/0194599812450681
  23. Hutchings D, White S. Coming round to recycling. BMJ 2009;338:746–748. DOI: 10.1136/bmj.b609
  24. Lee B-K, Ellenbecker MJ, Moure-Eraso R. Analysis of the recycling potential of medical plastic wastes. Waste Manag 2002(5);22:461–470. DOI: 10.1016/s0956-053x(02)00006-5
  25. Nussbaum GF. Alternative waste management strategies. Perioperative Nurs Clin 2008;3(1):63–72. doi: 10.1016/j.cpen.2007.11.009 
  26. Kaiser B, Eagan PD, Shaner H. Solutions to healthcare waste: Life-cycle thinking and ‘green’ purchasing. Environ Health Perspect 2001;109(3):205–207. DOI: 10.1289/ehp.01109205
  27. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 18]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  28. Standards Australia. AS 3816:2018 Management of clinical and related wastes. Sydney: 2018; Standards Australia.
  29. Australian and New Zealand Clinical Waste Management Industry Group (ANZCWMIG). Industry code of practice for the management of clinical and related waste [Internet]. 5th ed. WMAA; 2007[cited 2014 February 18]. Formerly available from: www.wmaa.asn.au. 
  30. Biohazardous Waste Industry (BWI). Industry code of practice for management of clinical and related waste 6th ed. [Internet]. Sydney: BWI; 2010 [cited 2014 April 23]. Formerly available from: www.epa.sa.gov.au/xstd_ files/Waste/Code%20of%20practice/Code%20of%20 Practice%206th%20Edition.pdf. 
  31. Lauer M. Reducing health care’s ecological footprint. How nurses can slow the flow of health care waste. AJN 2009;109(2):56–58.DOI: 10.1097/01.NAJ.0000345439.68228.a0
  32. Saver C. Staff spearheads an OR’s green effort. OR Manager 2009;25(1):24–25.
  33. McGain F, White S, Mossenson S, Kayak E, Story D. A survey of anesthesiologists’ views of operating room recycling. Anesth Analg 2012 May;114(5):1049–1054. DOI: 10.1213/ANE.0b013e31824d273d
  34. Overcash M. A comparison of re-usable and disposable perioperative textiles: Sustainability state-of-the-art 2012. Anesth Analg 2012;114(5):1055–1066. DOI: 10.1213/ANE.0b013e31824d9cc3
  35. Fritz J, Braun R. Environmental impacts of biobased/ biodegradable packaging. Starch 2001;53(3–4):105–109. https://doi.org/10.1002/1521-379X(200104)53:3/4<105::AID-STAR105>3.0.CO;2-I
  1. Safe Work Australia. Guide for managing the risk of fatigue at work [Internet]. Canberra: Safe Work Australia; 2013 [cited 2020 March 4]. Available from: www.safeworkaustralia.gov.au/search/site/Guide%20 for%20managing%20the%20risk%20of%20fatigue%20 at%20work. 
  2. Warren A, Tart RC. Fatigue and charting errors: The benefit of a reduced call schedule. AORN J 2008;88(1):88–95. DOI: 10.1016/j.aorn.2008.03.016
  3. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388(6639):235–237.DOI: 10.1038/40775
  4. Rogers AE. The working hours of hospital staff nurses and patient safety. Health Aff (Milwood) 2004; 23(4):202–212. DOI: 10.1377/hlthaff.23.4.202
  5. Registered Nurses’ Association of Ontario (RNAO). Preventing and mitigating nurse fatigue in health care [Internet]. Toronto: RNAO; 2011 [cited 2020 March 4]. Available from: www.rnao.ca/bpg/guidelines/preventing-and-mitigating-nurse-fatigue-health-care.  
  6. Hughes NL, Nelson A, Matz MW, Lloyd J. AORN ergonomic tool 4: Solutions for prolonged standing in perioperative settings. AORN J 2011;93(6):767–774. DOI: 10.1016/j.aorn.2010.08.029
  7. Kenyon TAG, Gluesing RE, White KY, Dunkel WL, Burlingame BL. On call: Alert or unsafe? A report of the AORN on-call electronic task force. AORN J 2007;86(4):630–639. DOI: 10.1016/j.aorn.2007.06.020
  8. Drake DA, Luna M, Georges JM, Steege LM. Hospital nurse force theory: A perspective of nurse fatigue and patient harm. Adv Nurs Sci 2012;35(4):305–314. DOI: 10.1097/ANS.0b013e318271d104
  9. Dorrian J, Lamond N, van den Heuvel C, Pincombe J, Rogers AE, Dawson D. A pilot study of the safety implications of Australian nurses’ sleep and work hours. Chronobiol Int 2006;23(6):1149–1163. DOI: 10.1080/07420520601059615
  10. Association of periOperative Registered Nurses. AORN guidance statement: Safe on-call practices in perioperative practice settings. In: Perioperative standards and recommended practices. Denver: AORN; 2013, 549–552. 
  11. Paterson-Brown S. Improving patient safety in the operating room – everyone’s responsibility. Clin Risk 2010;16(1):6–9. DOI: 10.1258/cr.2009.090006
  12. Gaba DM, Howard SK. Patient safety: Fatigue among clinicians and the safety of patients. N Engl J Med 2002;347(16):1249–1255.DOI: 10.1056/NEJMsa020846
  13. Hazzard B, Johnson K, Dordunoo D, Klein T, Russell B, Walkowiak P. Work- and nonwork-related factors associated with PACU nurses’ fatigue. J Perianesth Nurs 2013;28(4):201–209.DOI: 10.1016/j.jopan.2012.06.010
  14. Reed K. Promoting healthy work hours for nurses. Nursing 2013;43(1):64–65.DOI: 10.1097/01.NURSE.0000422658.39909.37
  15. Australian Nursing Federation (ANF). Fatigue prevention policy [Internet]. Canberra: ANF; 2013 [cited 2020 March 4]. Available from: www.anmf.org.au/documents/ policies/P_Fatigue_prevention.pdf. 
  16. The Joint Commission. Health care worker fatigue and patient safety. The Joint Commission Sentinel Event Alert December 2011; Issue 48 [cited 2014 December 09]. Formerly available from: www.jointcommission.org/assets/1/18/SEA_48.pdf. 
  17. WorkCover Queensland. Managing fatigue [Internet]. Brisbane: Workcover Queensland; [updated 11 Nov 2014; cited 2020 March 4]. Available from: www.worksafe.qld.gov.au/injury-prevention-safety/ workplace-hazards/fatigue/managing-fatigue. 
  18. Canadian Nurses Association and Registered Nurses’ Association of Ontario. Nurse fatigue and patient safety: Research report 2010 [Internet]. Ottawa: Canadian Nurses Association; 2010 [cited 2020 March 4]. Available from: www.cna-aiic.ca/en/on-the-issues/better-care/patient-safety/nurse-fatigue-and-patient-safety. 
  19. WorkSafe Victoria. Fatigue prevention in the workplace [Internet] Melbourne: WorkSafe Victoria 2019 [cited 2020 March 4]. Available from: www.worksafe.vic.gov.au/ resources/fatigue-prevention-workplace-your-health-and-safety-guide. 
  20. Canadian Nurses Association. Report on fatigue recommends actions at many levels. Can Nurse 2010;106(5):12–14. 
  21. American Society of PeriAnesthesia Nurses (ASPAN). Position statement 7. A position statement on ‘On call/work schedule’ (last update 2011). In: 2012– 2014 Perianesthesia nursing standards, practice, recommendations and interpretive statements. Cherry Hill, New Jersey: ASPAN; 2014. 
  22. Yuan SC, Chou MC, Chen CJ, Lin YJ, Chen MC, Liu HH et al. Influences of shift work on fatigue among nurses. J Nurs Manag 2011;19(3):339–345. DOI: 10.1111/j.1365-2834.2010.01173.x
  23. Bahr S, Buth C, Martin R, Peters N, Swanson K, Warhanek J et al. White paper: Nurse scheduling and fatigue in the acute 24 hour setting. Milwaukee: Wisconsin Organization of Nurse Executives; 2008 [cited 2020 March 4]. Available from: www.ena.org/docs/default-source/resource-library/ practice-resources/white-papers/nurse-fatigue. 
  24. Olson L, Ambrogetti A. Working harder – Working dangerously. Fatigue and performance in hospitals. Med J Aust 1998;168(12):614–616. https://doi.org/10.5694/j.1326-5377.1998.tb141449.x
  25. Chen J, Davis KG, Daraiseh NM, Pan W, Davis LS. Fatigue and recovery in 12-hour dayshift hospital nurses. J Nurs Manag 2014; 22(5):593–603. DOI: 10.1111/jonm.12062
  26. Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmit JM. Overtime and extended work shifts: Recent findings on illnesses, injuries and health behaviours [Internet]. Ohio: US Department of Health and Human Services/ CDC/NIOSH; 2004 [cited 2020 March 4]. Available from: www.cdc.gov/niosh/docs/2004-143/pdfs/2004-143.pdf. 
  27. Winwood PC, Lushington K. Disentangling the effects of psychological and physical work demands on sleep, recovery and maladaptive chronic stress outcomes within a large sample of Australian nurses. J Adv Nurs 2006;56(6):679–689. DOI: 10.1111/j.1365-2648.2006.04055.x
  28. Steege LM, Drake DA, Olivas M, Mazza G. Evaluation of physically and mentally fatiguing tasks and sources of fatigue as reported by registered nurses. J Nurs Manag 2015;23(2):179–189. DOI: 10.1111/jonm.12112
  29. Australian and New Zealand College of Anaesthetists (ANZCA). Guideline on fatigue risk management in anaesthesia practice [Internet]. Melbourne: ANZCA; 2019 [cited 2020 March 4]. Available from: www.anzca.edu.au/documents/ps43-2007-statement-on-fatigue-and-the-anaesthetis.pdf.
  30. Rosekind MR. Managing work schedules: An alertness and safety perspective [Internet]. San Jose: Northern California Business Aviation Association; 2005 [cited 2014 Dec 08]. Available from: www.norcalbaa.org/uploads/ NCBAA_ARTICLES_20110825_Alertness_Solutions_ Managing_Work_Schedules.pdf. 
  31. Work, Health and Safety Act 2011, No. 137, 2011. 
  32. Skinner N, Hutchinson C, Pocock B. Australian work and life index – the big squeeze: Work home and care in 2012 [Internet]. Adelaide: University of South Australia; 2012 [cited 2020 March 4]. Available from: https://pdfs.semanticscholar.org/ d7c6/2ddbdcc5fd38b37effdaa919d81f78874827.pdf. 
  33. Beyea SC. Too tired to work safely? AORN J 2004;80(3):559–562.DOI: 10.1016/s0001-2092(06)60546-2
  34. Goldberg JL, Marshalkowski PL, Nissen RB. The importance of mandatory rest periods in OR environments. AORN J 2008;88(5):790–797. DOI: 10.1016/j.aorn.2008.04.018
  35. Monahan JJ. Culture of safety: Safe work hours in the OR. AORN J 2012;95(1):149–154.DOI: 10.1016/j.aorn.2011.11.003
  36. Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J 2008;87(6):1191–1192, 1194, 1196–1204.https://doi.org/10.1016/j.aorn.2008.01.022 
  37. Cohoon B. Causes of near misses: Perceptions of perioperative nurses. AORN J 2011;93(5):551–565. DOI: 10.1016/j.aorn.2010.02.017
  38. Scott LD, Hofmeister N, Rogness N, Rogers AE. An interventional approach for patient and nurse safety: A fatigue countermeasures feasibility study. Nurs Res 2010;59(4):250–258.DOI: 10.1097/NNR.0b013e3181de9116
  39. Queensland Health. Fatigue risk management system: Resource pack. Brisbane: Queensland Government; 2009 [cited 2014 Dec 08]. Formerly available from: www.enhancingresponsibility.com/wp-content/ uploads/2014/01/Queensland-Health-Fatigue-Risk- Management-System-resource-pack-2009.pdf. 
  40. World Health Organization (WHO). Human factors in patient safety: Review of topics and tools [Internet]. Geneva: WHO; 2009 [cited 2020 March 4]. Available from www.who.int/patientsafety/research/methods_measures/ human_factors/human_factors_review.pdf. 
  41. Brewer K. How a ‘just culture’ can improve safety in health care. Am Nurse Today 2011;6. 
  42. Bae S. Nurse overtime, working conditions, and the presence of mandatory nurse overtime regulations. Workplace Health Saf 2012; 60(5):205–214. DOI: 10.1177/216507991206000504
  43. Graves K, Simmons D. Reexamining fatigue: Implications for nursing practice. Crit Care Nurs Q 2009;32(2):112–115.DOI: 10.1097/01.CNQ.0000348198.16788.df
  44. Neft M, Greenier E. An update from the AANA Practice Committee: Application of the the evidence-based process. AANA J 2013;81(1):9–12. [D]
  1. NSW Department of Health. Policy directive PD2009_062: Fire safety in health care facilities – Guidelines. Sydney: NSW Health; 2009.
  2. Graling P. Fighting fire with fire safety. AORN J 2006;84(30):561–563. DOI: 10.1016/S0001-2092(06)63933-1
  3. Smith C. Surgical fires: Learn not to burn. AORN J 2006;80(1):23–40. DOI: 10.1016/s0001-2092(06)60840-5
  4. Salmon L. Fire in the OR: Prevention and preparedness. AORN J 2004; 80(1):41–60. DOI: 10.1016/s0001-2092(06)60842-9
  5. Rinder C. Fire safety in the operating room. Curr Opin Anesthesiol 2008;21:790–795. DOI: 10.1097/ACO.0b013e328318693a
  6. Best practices for fire prevention in perioperative settings. AORN J 2006;84(1):537–544. https://doi.org/10.1016/S0001-2092(06)60084-7
  7. Rothrock J. Alexander’s care of the patient in surgery. 15th ed. Mosby: St Louis; 2014.
  8. American Society of Anaesthesiologists. Taskforce on operating room fires: Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008;108(5):786–801. DOI: 10.1097/01.anes.0000299343.87119.a9
  9. Retzlaff K. Fighting fire with preparation [Internet]. AORN: Denver; 2009 [cited 2009 October 12]. Formerly available from: www.aorn.org/news/october2009news/fire.
  10. Beyea S. Preventing fires in the OR. AORN J 2003;78(4):664–666. DOI: 10.1016/s0001-2092(06)60673-x
  11. Massachusetts Department of Public Health. Health care quality and safety alert: Preventing operating room fires during surgery. Boston: Department of Public Health; 2002.
  12. Surgicalfire.org. Surgical fires online resource [Internet]. Boonsboro: SurgicalFire.org; n.d. [cited 2017 September 20]. Available from: Previously available from www.surgicalfire.org
  13. Hamlin L, Richardson-Tench M, Davies M. Perioperative nursing: An introductory text. Sydney: Mosby; 2009, 61–62.
  14. McCarthy P, Gaucher K. Fire in the OR – Developing a fire safety plan. AORN J 2004;79(3):588–604. DOI: 10.1016/s0001-2092(06)60910-1
  15. ECRI Institute. Medical device safety report – The patient is on fire! A surgical fire primer [Internet]. Philadelphia: ECRI Institute; n.d. [cited 2017 September 20]. Available from: www.mdsr.ecri.org/summary/detail. aspx?doc_id=8197 id=8197.
  16. Tooher R, Maddern G. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004;74(5):382–385. DOI: 10.1111/j.1445-1433.2004.02997.x
  1. Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016;387(10038):2655–2664. DOI: 10.1016/S0140-6736(15)00981-2. DOI: 10.1016/S0140-6736(15)00981-2
  2. National Collaborating Centre for Nursing and Supportive Care. Clinical practice guideline. The management of inadvertent perioperative hypothermia in adults. London: National Institute for Clinical Health and Excellence; 2008 (updated 2016). NBK53797
  3. Hooven K. Preprocedure warming maintains normothermia throughout the perioperative period: A quality improvement project. J Perianesth Nurs 2011;26(1):9–14. DOI: 10.1016/j.jopan.2010.07.013
  4. Munday J, Hines S, Chang AM. Evidence utilisation project: Management of inadvertent perioperative hypothermia. The challenges of implementing best practice recommendations in the perioperative environment. Int J Evid Based Healthc 2013;11(4):305–311. DOI: 10.1111/1744-1609.12035
  5. Chakladar A, Harper C. Perioperative warming in caesarean sections: Guidance would be NICE. Anaesthesia 2010;65(2):212–213. DOI: 10.1111/j.1365-2044.2009.06218.x
  6. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008;108(1):71–77. DOI: 10.1097/01.anes.0000296719.73450.52
  7. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334(19):1209–1216. DOI: 10.1056/NEJM199605093341901
  8. Beilin B, Shavit Y, Razumovsky J, Wolloch Y, Zeidel A, Bessler H. Effects of mild perioperative hypothermia on cellular immune responses. Anesthesiology 1998;89(5):1133–1140. DOI: 10.1097/00000542-199811000-00013
  9. Heier T, Caldwell JE. Impact of hypothermia on the response to neuromuscular blocking drugs. Anesthesiology 2006;104(5):1070–1080. DOI: 10.1097/00000542-200605000-00025
  10. Mahoney CB, Odom M. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA J 1999;67(2):155–164. https://pubmed.ncbi.nlm.nih.gov/10488289/
  11. Madrid E, Urrútia G, Roqué i Figuls M, Pardo-Hernandez H, Campos JM, Paniagua P et al. Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database Syst Rev 2016(4):CD009016. DOI: 10.1002/14651858.CD009016.pub2
  12. Munday J, Hines S, Wallace K, Chang AM, Gibbons K, Yates P. A systematic review of the effectiveness of warming interventions for women undergoing cesarean section. Worldviews Evid Based Nurs 2014;11(6):383–393. DOI: 10.1111/wvn.12067
  13. Duff J, Walker K, Edward KL, Williams R, Sutherland- Fraser S. Incidence of perioperative inadvertent hypothermia and compliance with evidence-based recommendations at four Australian hospitals: A retrospective chart audit. ACORN J 2014;27(3):20–23. 
  14. Alderson P, Campbell G, Smith AF, Wartigg S, Nicholson A, Lewis SR. Thermal insulation for preventing inadvertent perioperative hypothermia (review). Cochrane Database Syst Rev 2014(6):CD009908. DOI:10.1002/14651858.CD009908.pub2.
  15. Campbell G, Alderson P, Smith AF, Wartigg S. Warming of intravenous and irrigation fluids for preventing inadvertent perioperative hypothermia (review). Cochrane Database Syst Rev 2015(4):CD009891. DOI: 10.1002/14651858.CD009908.pub2
  16. Connelly C, Cramer E, DeMott Q, Winfield C, Swanberg M. The optimal time and method for surgical prewarming: A comprehensive review of the literature. J Perianesth Nurs 2017;32(3):199–209. DOI: 10.1016/j.jopan.2015.11.010
  17. Association of periOperative Registered Nurses (AORN). ‘Guideline for prevention of unplanned patient hypothermia’ in Guidelines for perioperative practice 15th ed. Denver: AORN; 2015: pp. 479–490. 
  18. Apfelbaum JL, Silverstein JH, Chung FF, Connis RT, Fillmore RB, Hunt SE et al. Practice guidelines for postanesthetic care: An updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2013;118(2):291–307. DOI: 10.1097/ALN.0b013e31827773e9
  19. Torossian A, Bräuer A, Höcker J, Bein B, Wulf H, Horn EP. Clinical practice guideline. Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int 2015;112(10),166–172. DOI: 10.3238/arztebl.2015.0166
  20. Shukry M, Matthews L, Armendi AJ, Kropp BP, Frimberger D, Cure JA. Does the covering of children during induction of anesthesia have an effect on body temperature at the end of surgery? J Clin Anesth 2012;24(2):116–120. DOI: 10.1016/j.jclinane.2011.06.017
  21. Australian and New Zealand College of Anaesthetists (ANZCA). PS18 BP 2017. Guidelines on monitoring during anaesthesia. Melbourne: ANZCA; 2017. 
  22. Tekgul ZT, Pektas S, Yildirim U, Karaman Y, Cakmak M, Ozkarakas H, Gonullu M. A prospective randomized double-blind study on the effects of the temperature of irrigation solutions on thermoregulation and post-operative complications in percutaneous nephrolithotomy. J Anesth 2015;29(2):165–169. https://doi.org/10.1007/s00540-014-1888-5  
  23. Australian Council on Healthcare Standards (ACHS). Australian Clinical Indicator Report 17th edition 2008–15. Sydney: ACHS; 2016. 
  1. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standard 3: Preventing and controlling healthcare associated infections [Internet]. Sydney: ACSQHC; 2017 [cited 2019 November 14]. Available from: www.safetyandquality.gov.au/standards/nsqhs-standards.  
  2. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in health care [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 18]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019. 
  3. Australian Government Department of Health. Infection Control Guidelines: Creutzfeldt–Jakob disease [Internet]. Australian Government:Canberra: 2013 [updated 2013 April15, cited 2020 March 20]. Available from: https://www1.health.gov.au/internet/main/ publishing.nsf/Content/icg-guidelines-index.htm. 
  4. Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations (incorporating Amendments No. 1 and 2). Sydney: Standards Australia; 2014. 
  5. Driscoll T. Occupational exposures of Australian nurses (archived) [Internet]. Canberra: Australian Safety and Compensation Council (ASCC); 2008 [cited 2019 November 14]. Available from: https://www. safeworkaustralia.gov.au/doc/occupational-exposures-australian-nurses-methodology-report. 
  6. Centers for Disease Control and Prevention (CDC). Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Morb Mortal Wkly Rep 2005;54(RR17):1–141 [cited 2019 November 14]. Available from: www.cdc.gov/ mmwr/preview/mmwrhtml/rr5417a1.htm. 
  7. Centers for Disease Control and Prevention (CDC). Workbook for designing, implementing and evaluating a sharps injury prevention program [Internet]. Atlanta: CDC; 2008 [cited 2019 November 14]. Available from: https://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf. 
  8. Centers for Disease Control and Prevention (CDC). Hand hygiene in healthcare settings 2002; 51:RR–16 [Internet]. Atlanta: CDC; 2002 [cited 2019 November 14]. Available from: https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html. 
  9. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standard 1: Clinical governance standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 18]. Available from: https://www.safetyandquality.gov.au/our-work/clinical-governance/clinical-governance-standard. 
  10. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards [Internet]. Sydney: ACSQHC; 2012 [cited 2020 March 18]. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards. 
  11. Association of periOperative Registered Nurses (AORN). Transmission-based precautions. In: AORN Guidelines for perioperative practice 2019. Denver: AORN; 2019; 1092–1120. 
  12. Tanavusa Lene M. Improving infection control practices through staff link programmes. Australian Infection Control 2002;7(1):19–26. https://doi.org/10.1071/HI02019 
  13. Tropea J, Brand C, Roberts C. A national stakeholder review of Australian infection control programs: The scope of practice of the infection control professional. Final draft report 24 October [Internet]. Sydney: Australian Commission on Safety and Quality in Health Care; 2008 [cited 2014 February 20]. Formerly available from: www.safetyandquality.gov.au/publications/ review-of-australian-infection-control-programs-the-scope-of-practice-of-the-infection-control-professionalpractition erconsultant-with-national-stakeholders. 
  14. Cruickshank M, Murphy C. Reducing harm to patients from healthcare associated infection: An Australian infection prevention and control model for acute hospitals [Internet]. Sydney: Australian Commission on Safety and Quality in Healthcare; 2009 [cited 2014 February 20]. Formerly available from: www. safetyandquality.gov. au/mediareleases/reducing-harm-to-patients-from-healthcare-associated-infections. 
  15. Osborne S. Perceptions that influence occupational exposure reporting. AORN J 2003;78(2):262–271. DOI: 10.1016/s0001-2092(06)60776-x
  16. Australian Commission on Safety and Quality in Health Care (ACSQHS). Patient-centred care: Improving quality and safety through partnerships with patients and consumers [Internet]. Sydney: ACSQHS; 2011 [cited 2020 March 18]. Available from: https://commission.safetyandquality.gov.au/publications/patient-centred-care-improving-quality-and-safety-through-partnerships-with-patients-and-consumers/
  17. Rowley S, Clare S. Improving standards of aseptic practice through an ANTT trust-wide implementation process: A matter of prioritisation and care. J Infect Prev 2009;10(1):18–23. https://doi.org/10.1177/1757177409342140 
  18. Australian Government Department of Health. Immunise Australia program – National Immunisation Program [Internet]. Canberra: Department of Health; 2013 [cited 2020 March 18]. Available from: www. health.gov.au/iniatives-and-programs/national-immunisation-program. 
  19. Occupational Safety and Health Administration (OSHA). Blood borne pathogens. Regulation 1910.1030 paragraph (d)(2)(ix) [Internet]. Washington: OSHA; 2012 [cited 2020 March 19]. Available from: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030
  20. Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla S et al. Measurement of foot traffic in the operating room: Implications for infection control. Am J Med Qual 2009;24(1):45–52. DOI: 10.1177/1062860608326419
  21. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20(4):250–278. DOI: 10.1086/501620
  22. Parikh SN, Grice SS, Schnell BM, Salisbury S. Operating room traffic: Is there any role of monitoring it? J Pediatr Orthop 2010;30(6):617–623. DOI: 10.1097/BPO.0b013e3181e4f3be
  23. Standards Australia / Standards New Zealand. AS/NZS 1668.2:2012 The use of ventilation and air conditioning in buildings – Part 2: Mechanical ventilation in buildings [Internet]. Sydney: Standards Australia; 2012 [cited 2020 March 18]. Available from: https://infostore.saiglobal.com/en-au/standards/as-1668-2-2012-120207_saig_as_as_251941/
  24. Workplace British Columbia. Occupational Health and Safety Regulation. Section 4.84 Eating areas (enacted 1 Jan 2005) [cited February 20, 2014]. Formerly available from: www2.worksafebc.com/Publications/ OHSRegulation/Home.asp. 
  25. Work, Health and Safety Act 2011, No. 137. 
  26. Pyrek KM. Breaking the chain of infection [Internet]. Phoenix: Infection Control Today; 2002 [cited 2020 March 18]. Available from: www.infectioncontroltoday. com/hand-hygiene/breaking-chain-infection. 
  27. Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. What’s hanging around your neck? Pathogenic bacteria on identity badges and lanyards. Med J Aust 2008;188(1):5–8. https://doi.org/10.5694/j.1326-5377.2008.tb01494.x 
  28. Jarvis WR. The Lowbury Lecture. The United States approach to strategies in the battle against healthcare associated infections: Transitioning from benchmarking to zero tolerance and clinician accountability. J Hosp Infect 2007;65(S2):3–9. DOI: 10.1016/S0195-6701(07)60005-X
  29. Communicable Diseases Network of Australia (CDNA). Creutzfeldt–Jakob disease [Internet]. Canberra: CDNA; 2013 [cited 2020 March 18]. Available from: www.health. gov.au/internet/main/publishing.nsf/ Content/icg-guidelines-index.htm. 
  30. New South Wales Health. Alcohol-based hand cleansers and fire. NSW Health Safety Information S1:001/07 [Internet]. Sydney: NSW Department of Health; 2007 [cited 2020 March 18]. Available from: www.health.nsw.gov.au/sabs/ Documents/2007-si-001. pdf
  31. Whitby M, Pessoa-Silva CL, McLaws M-L, Allegranzi B, Sax H, Larson E et al. Behavioural considerations for hand hygiene practices: The basic building blocks. J Hosp Infect 2007;65(1):1–8. DOI: 10.1016/j.jhin.2006.09.026
  32. Barie PS, Eachempati SR. Surgical site infections. Surg Clin North Am 2005;85(6):1115–1135. DOI: 10.1016/j.suc.2005.09.006
  33. Hand Hygiene Australia (HHA). Five moments for hand hygiene manual. Melbourne: HHA; 2013 [cited 2020 March 18]. Available from: www.hha.org.au/hand-hygiene/5-moments-for-hand-hygiene. 
  34. World Health Organization (WHO). WHO guidelines on hand hygiene in health care. Geneva: WHO; 2009 [cited 2020 March 18]. Available from: www.who.int/ gpsc/5may/tools/9789241597906/en. 
  35. Garbutt SJ. Hand hygiene in the OR: Using evidence-based practices. OR Nurse 2011;5(2):10–12. 
  36. Patrick M, Van Wicklin S. Implementing AORN recommended practices for hand hygiene. AORN J 2012;95(94):492–507. DOI:10.1016/j.aorn.2012.01.019. DOI: 10.1016/j.aorn.2012.01.019
  37. New South Wales (NSW) Health. PD2017_013 Infection Prevention and Control Policy [Internet]. Sydney: NSW Department of Health; 2010 [cited 2019 November 14]. Available from: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_013.pdf. 
  38. New South Wales (NSW) Health. Infection Control Policy PD 2007036 (Rescinded) [Internet]. Sydney: NSW Department of Health; 2007 [cited 2014 February 20]. Formerly available from: www1.health.nsw.gov.au/PDS/ pages/doc. aspx?dn=PD2007036. 
  39. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6(10):641– 652. DOI: 10.1016/S1473-3099(06)70600-4
  40. Spruce L. Back to basics: Hand hygiene and surgical hand antisepsis. AORN J 2013;98(5):449–460. DOI: 10.1016/j.aorn.2013.08.017
  41. Johnson PDR, Martin R, Burrell LJ, Grabsch EA, Kirsa SW, O’Keeffe J et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005;183(10):509– 514. 
  42. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: A user-centred design and approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67(1):9–21. DOI: 10.1016/j.jhin.2007.06.004
  43. Hand Hygiene Australia (HHA). Risk assessment for use of alcohol-based hand rubs in healthcare facilities [Internet]. Melbourne: HHA; 2009 [cited 2014 February 20]. Formerly available from: www.hha.org. au/UserFiles/ file/GenericAlcoholBasedHandRubRisk Assessmentv2.pdf. 
  44. Queensland Health. Hand hygiene – fire and safety issues. Alcohol Based Hand Rub (ABHR) [Internet]. Queensland Health; 2013 [cited 2014 February 20]. Formerly available from: www.health.qld.gov.au/chrisp/ handhygiene/safety.pdf. 
  45. Bellaard-Smith E. Gillespie E. Implementing hand hygiene strategies in the operating suite. Healthcare Infect 2012;17(1):33–37. DOI:https://doi.org/10.1071/HI12002 
  46. Krediet A, Kalkman C, Bonten M, Gigengack A, Barach P. Hand-hygiene practices in the operating theatre: An observational study. Br J Anaesth 2011;104(7):553–558. DOI: 10.1093/bja/aer162
  47. Korniewicz D, El-Masri M. Exploring the benefits of double gloving during surgery. AORN J 2012;95(3):328– 336. DOI: 10.1016/j.aorn.2011.04.027
  48. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev 2006;(3). DOI: 10.1002/14651858.CD003087.pub2
  49. Association of periOperative Registered Nurses (AORN). Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices, pp. 57–72. Denver: AORN Inc; 2011.  
  50. Rowley S, Clare S, Macqueen S, Molyneux R. ANTTv2: An updated practice framework for aseptic technique. Br J Nurs 2010;19(5):5–11. https://doi.org/10.12968/bjon.2010.19.Sup1.47079 
  51. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007;65S:S1–64. DOI: 10.1016/S0195-6701(07)60002-4
  52. Watt A, Patkin M, Sinnott MJ, Black RJ, Maddern G. Scalpel safety in the operative setting: A systematic review. Surgery 2010;147(1):98–106. DOI: 10.1016/j.surg.2009.08.001
  53. World Health Organization (WHO). WHO guidelines for safe surgery: Safe surgery saves lives [Internet]. Geneva: World Health Organization; 2009 [cited 2014 February 20]. Available from: www.who.int/patientsafety/safesurgery/tools resources/9789241598552/en. 
  1. Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations (incorporating Amendments No. 1 and 2). Sydney: Standards Australia; 2014. 
  2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Preventing and controlling healthcare associated infections [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 4]. Available from: www.safetyandquality.gov.au/ publications/national-safety-and-quality-health-service-standards. 
  3. Anonymous. Central reprocessing: is it time to add instrument tracking? OR Manager 2007;23(8):14–15.
  4. Anonymous. 2005 surgical instruments guide: Cardinal rules on surgical instrument management. Healthcare Purchasing News 2005;29(4):24–30.
  1. Standards Australia / Standards New Zealand. AS/NZS 4173:2018 Safe use of lasers and intense light sources in health care. Sydney: Standards Australia; 2018.
  1. Mertes PM, Ebo DG, Garcez T, Rose M, Sabato V, Takazawa T et al. Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019;123(1):e16–e28. DOI: 10.1016/j.bja.2019.01.027
  2. Dardeer A, Shallik N. Perioperative anaphylaxis: A new visit to an old topic. Trends Anaesth Crit Care 2019;26– 27:(1–10). https://doi.org/10.1016/j.tacc.2019.04.005
  3. Di Leo E, Delle Donne P, Calogiuri GF, Macchia L, Nettis E. Focus on the agents most frequently responsible for perioperative anaphylaxis. Clin Mol Allergy 2018;16:16. DOI: 10.1186/s12948-018-0094-7
  4. Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: Potential, limitations, and perspectives. Br J Anaesth 2019;123(1):e117–e125. https://doi.org/10.1016/j.bja.2019.01.002
  5. Ebo DG, Van Gasse AL, Decuyper II, Uyttebroek A, Sermeus LA, Elst J et al. Acute management, diagnosis, and follow-up of suspected perioperative hypersensitivity reactions in Flanders 2001–2018. J Allergy Clin Immunol Pract 2019;7(7): 2194–2204.e7. DOI: 10.1016/j.jaip.2019.02.031
  6. Volcheck GW, Hepner DL. Identification and management of perioperative anaphylaxis. J Allergy Clin Immunol Pract 2019;7(7): 2134–2142. DOI: 10.1016/j.jaip.2019.05.033
  7. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 February 2]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  8. Australasian Society of Clinical Immunology and Allergy (ASCIA). Latex allergy [Internet]. Brookvale NSW: ASCIA; 2019 [cited 2020 February 2]. Available from: www.allergy.org.au/patients/other-allergy/latex-allergy
  9. Adriaensens I, Vercauteren M, Soetens F, Janssen L, Leysen J, Ebo D. Allergic reactions during labour analgesia and caesarean section anaesthesia. Int J Obstet Anesth 2013;22(3):231–242. DOI: 10.1016/j.ijoa.2013.04.010
  10. Association of periOperative Registered Nurses (AORN). Guidelines for perioperative practice: Environment of care. Denver CO: AORN; 2019.
  11. Péer L, Brezis ML, Shalit M, Carvalho B, Levin PD, Seri O et al. Evaluation of a prospectively administered written questionnaire to reduce the incidence of suspected latex anaphylaxis during elective cesarean delivery. Int J Obstet Anesth 2014;23(4):335–340. https://doi.org/10.1016/j.ijoa.2014.05.009
  12. Provinciael S, Saldien V, Hans G, Vercauteren M. Perioperative allergy and anaphylaxis in children: A review. Acta Anaesthesiologica Belgica 2018;69(1):13–24.
  13. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACSQHC; 2017.
  14. Therapeutic Goods (Charges) Act 1989.
  15. Therapeutic Goods (Medical Devices) Regulations 2002.
  16. Therapeutic Goods Administration (TGA). Therapeutic goods (standard for disinfectants and sanitary products) (TGO 104) order 2019. Canberra: TGA; 2019.
  17. Therapeutic Goods Administration (TGA). Guidelines for the evaluation of sterilants and disinfectants. Canberra: TGA; 1998.
  18. Therapeutic Goods Administration (TGA). Australian register of therapeutic goods. Canberra: TGA; 2019.
  19. Wood A. Updates to the AORN evidence rating model. AORN J 2019;110(1):5–8. DOI: 10.1002/aorn.12744
  20. Association of periOperative Registered Nurses (AORN). AORN guidelines for perioperative practice 2019. Denver: AORN; 2019.
  21. Katelaris CH. Latex allergy [Internet]. Sydney; Allergy and Anaphylaxis Australia; 2012 [updated 2017 January, cited 2020 February 2]. Available from: allergyfacts.org. au/images/pdf/latex.pdf
  22. American Association of Nurse Anesthetists (AANA). Latex allergy management [Internet]. Illinois: AANA; 2018 [cited 2020 February 2]. Available from: www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/latex-allergy-management. pdf?sfvrsn=9c0049b1_8
  23. Epling C, Duncan J, Archibong E, Østbye T, Pompeii LA, Dement J. Latex allergy symptoms among health care workers: Results from a university health and safety surveillance system. Int J Occup Environ Health 2011;17(1):17–23. DOI: 10.1179/107735211799031176
  24. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines on the perioperative management of patients with suspected or proven hypersensitivity to chlorhexidine. Melbourne: ANZCA; 2016.
  25. Scolaro RJ, Crilly HM, Maycock EJ, McAleer PT, Nicholls KA, Rose MA et al. Australian and New Zealand anaesthetic allergy group perioperative anaphylaxis investigation guidelines. Anaesth Intensive Care 2017;45(5):543–555. DOI: 10.1177/0310057X1704500504
  26. Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R et al. Management of suspected immediate perioperative allergic reactions: An international overview and consensus recommendations. Br J Anaesth 2019;123(1):e50–e64. DOI: 10.1016/j.bja.2019.04.044
  27. Australian Nursing and Midwifery Federation (ANMF). Occupational health and safety [Internet]. Canberra: ANMF; 2018 [cited 2020 February 2]. Available from: http://anmf.org.au/documents/policies/P_ Occupational_health_and_safety.pdf
  1. Haas JP. Managing loaner instruments safely. OR Nurses Journal 2011;5(4):12–13.
  2. Huter-Kunish GG. Processing loaned instruments in an ambulatory surgery center. AORN J 2009;89(5):861–866. DOI: 10.1016/j.aorn.2009.02.002 
  3. Queensland Health. Guidelines – Management of loan set instruments. Brisbane: Queensland Health; 2013. 
  4. Seavey R. High-level disinfection, sterilization and antisepsis: Current issues on reprocessing medical and surgical instruments. Am J Infect Control 2013;41(5 Suppl):S111–S117. DOI: 10.1016/j.ajic.2012.09.030 
  5. Seavey R. Reducing the risks associated with loaner instrumentation and implants. AORN J 2010;92(3):322–331. DOI: 10.1016/j.aorn.2009.12.032 
  6. Seavey R. Getting a handle on loaner instrumentation [Internet]. Worthing UK: healthVIE.com Mar:71–89; 2011 [cited 2020 March 18]. Available from: http:// multimedia.3m.com/mws/media/788638O/getting-a-handle-on-loaner-instrumentation.pdf
  7. Duro M. New IAHCSMM loaner instrumentation position paper and policy template. AORN J 2011;94(3):287–289. DOI: 10.1016/j.aorn.2011.07.002 
  8. Festa M, Young M. Working together: Manufacturers’ instructions crucial to sterilization. Biomed Instrum Technol 2011;45(4):302–304. DOI: 10.2345/0899-8205-45.4.302 
  9. Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations (incorporating Amendments No. 1 and 2). Sydney: Standards Australia; 2014. 
  10. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards [Internet]. Sydney: ACSQHC; 2012 [cited 2020 March 18]. Available from: www. safetyandquality.gov.au/standards/nsqhs-standards. 
  11. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 18]. Available from: www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  12. Ricupito G. Consignment trays and the hidden costs of sterilization. Mater Manag Health Care 2006;15(12):32– 36. 
  13. Young M. Top 10 risks in sterile processing. Horizons 2012;Spring:15–19. DOI: 10.2345/0899-8205-12.1.15 
  14. Alfa MJ. Monitoring and improving the effectiveness of cleaning medical and surgical devices. Am J Infect Control 2013;41(5 Suppl):S56–S59. DOI: 10.1016/j.ajic.2012.12.006 
  15. WorkSafe Victoria. Guidance note: Orthopaedic surgical instrument sets – Reducing risks of musculoskeletal disorders. Melbourne: WorkSafe Victoria; 2005. Formerly available from: www.worksafe.vic.gov.au/ forms-and-publications/forms-and-publications/ orthopaedicsurgical-instrument-sets-reducing-risks-of-musculoskeletal-disorders. 
  16. WorkCover New South Wales. Design and handling of surgical instrument transport cases. A guide on health and safety standards, 2011 [Internet]. Catalogue No. WC03046. Sydney: WorkCover NSW; 2011 [cited 2015 November 29]. Formerly available from: www.workcover. nsw.gov. au/data/assets/pdf_file/0003/15258/design_ handling_ surgical_instrument_transport_cases_3046. pdf. 
  17. Standards Australia / Standards New Zealand. AS/ NZS 3551:2012 Management programs for medical equipment. Sydney: Standards Australia; 2012. 
  18. Rutala WA, Weber DJ. Guideline for disinfection and sterilization of prion-contaminated medical instruments. Infect Control Hosp Epidemiol 2010;31(2):107–117. DOI: 10.1086/650197 
  19. Communicable Diseases Network Australia (CDNA). Infection control guidelines Creutzfeldt-Jakob disease (CJD) [Internet]. Canberra: CDNA; 2013 [cited 2020 March 18]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/3A968399995CFCE5CA257BF000211E32/$File/CJDInfectionControlGuidelinesJan2013.pdf. 
  20. Australian Government Department of Health. Infection Control Guidelines: Creutzfeldt–Jakob disease [Internet]. Australian Government:Canberra: 2013 [updated 2013 April15, cited 2020 March 20]. Available from: www1.health.gov.au/internet/main/publishing. nsf/Content/icg-guidelines-index.htm
  21. World Health Organization. Practical guidelines for infection control in health care facilities. SEARO Regional Publication No. 41. New Delhi: World Health Organization, Regional Office for South-East Asia and Regional Office for Western Pacific; 2004. https://apps.who.int/iris/handle/10665/206946 
  1. Ogg MJ. Introduction to the safe patient handling and movement series. AORN J 2001;93(3):331–333. DOI: 10.1016/j.aorn.2010.12.004 
  2. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson. AORN ergonomic tool 1: Lateral transfer of a patient from a stretcher to an OR bed. AORN J 2011;93(3):2234– 2339. DOI: 10.1016/j.aorn.2010.08.025 
  3. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 2: Positioning and repositioning the supine patient on the OR bed. AORN J 2011;93(4):445–449. DOI: 10.1016/j.aorn.2010.08.027
  4. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson. AORN ergonomic tool 3: Lifting and holding the patient’s legs, arms, and head while prepping. AORN J 2011;93(5):589–592. DOI: 10.1016/j.aorn.2010.08.028 
  5. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 4: Solutions for prolonged standing in perioperative settings. AORN J 2011;93(6):767–764. DOI: 10.1016/j.aorn.2010.08.029 
  6. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson AORN ergonomic tool 5: Tissue retraction in the perioperative setting. AORN J 2011;94(1):54–58. DOI: 10.1016/j.aorn.2010.08.031
  7. Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 6: Lifting and carrying supplies and equipment in the perioperative setting. AORN J 2011;94(2):173–179. DOI: 10.1016/j.aorn.2010.09.033 
  8. Waters T, Lloyd JD, Hernandez A. AORN ergonomic tool 7: Pushing, pulling and moving equipment on wheels. AORN J 2011;94(3):254– 259. DOI: 10.1016/j.aorn.2010.09.035
  9. Dybec RB. Intraoperative positioning and care of the obese patient. Plast Surg Nurs 2004;24(3):118–122. DOI: 10.1097/00006527-200407000-00009
  10. Cowley SP, Leggett S. Manual handling risks associated with the care, treatment and transportation of bariatric patients and clients in Australia. Int J Nurs Pract 2010;16(3):262–267. DOI: 10.1111/j.1440-172X.2010.01839.x 
  11. Hignett S, Griffiths P. Risk factors for moving and handling bariatric patients. Nurs Stand 2009; 24(11):40–48. DOI: 10.7748/ns2009.11.24.11.40.c7390 
  12. Muir M, Heese GA, McLean D, Bodnar S, Rock BL. Handling of the bariatric patient in critical care: A case study of lessons learned. Crit Care Nurs Clin North Am 2007;19(2):223–224. DOI: 10.1016/j.ccell.2007.02.010
  13. Bennicoff G. Perioperative care of the morbidly obese patient in the lithotomy position. AORN J 2010;92(3):297– 309. DOI: 10.1016/j.aorn.2010.04.016
  14. Primiano M, Friend M, McClure C, Nardi S, Fix L, Schafer M et al. Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN J 2011;94(6):555–566. DOI: 10.1016/j.aorn.2011.03.014
  15. Hignett S. Intervention strategies to reduce musculoskeletal injuries associated with handling patients: A systematic review. Occup Environ Med 2003;60:E6. DOI: 10.1136/oem.60.9.e6
  1. Rich DS. New JCAHO medication management standards for 2004. Am J Health Syst Pharm 2004;61:1349–1358. DOI: 10.1093/ajhp/61.13.1349
  2. Roughead EE, Semple SJ. Medication safety in acute care in Australia: Where are we now? Part 1: A review of the extent and causes of medication problems 2002–2008. Aust New Zealand Health Policy. 2009;6:18. DOI: 10.1186/1743-8462-6-18. DOI: 10.1186/1743-8462-6-18
  3. Semple SJ, Roughead EE. Medication safety in acute care in Australia: Where are we now? Part 2: A review of strategies and activities for improving medication safety 2002–2008. Aust New Zealand Health Policy. 2009 Sep 22;6:24. DOI: 10.1186/1743-8462-6-24. DOI: 10.1186/1743-8462-6-24
  4. Roughead EE, Semple SJ. Literature review: Medication safety in acute care in Australia. Australian Commission on Safety and Quality in Healthcare. 2008 July. 
  5. Beyea SC, Hicks RW, Becker SC. (2003b). Medication errors in the OR – a secondary analysis of MEDMARX. AORN J 2003;77(1):122,125–129,132–134. DOI: 10.1016/s0001-2092(06)61382-3
  6. Hicks RW, Wanzer LJ, Goeckner B. Perioperative pharmacology: A framework for perioperative medication safety. AORN J 2011;93(1):136–142. DOI: 10.1016/j.aorn.2010.08.020
  7. Abeysekera A, Bergman IJ, Kluger MT, Short TG. Drug error in anaesthetic practice: A review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia 2005;60:220–227. DOI: 10.1111/j.1365-2044.2005.04123.x
  8. Hanna GM, Levine WC. Medication safety in the perioperative setting. Anaesthesiol Clin 2011;29(1):135–144. DOI: 10.1016/j.anclin.2010.11.009
  9. The Australian Commission on Safety and Quality in Health Care (ACSQHC). Medication safety standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 23]. Available from: www.safetyandquality.gov.au/ standards/nsqhs-standards/medication-safety-standard
  10. Goeckner B, Gladu M, Bradley J, Bibb SCG, Hicks RW. Differences in perioperative medication errors with regard to organization characteristics. AORN J 2006;83(2):351–368. DOI: 10.1016/s0001-2092(06)60167-1
  11. Roughead EE, Bedford G. Medication Safety: Will adverse drug events be reduced? [Internet]. Sydney: The Australian Commission on Safety and Quality in Health Care (ACSQHC); n.d. [cited 2011 December 22]. Formerly available from: www.safetyandquality. gov.au/internet/safety/publishing.nsf/Content/ D0DABD9912D44A14CA257516000FDABB/$File/NatRep- Windows.PDF
  12. Brown-Brumfield D, De-Leon A. Adherence to a medication safety protocol: Current practice for labelling medications and solutions on the sterile field. AORN J 2010;91(5):610–617. DOI: 10.1016/j.aorn.2010.03.002
  13. Eichhorn JH. APSF hosts medication safety conference: Consensus group defines challenges and opportunities for improved practice. APSF Newsletter 2010;25:1–20. 
  14. Jensen LS, Merry AF, Webster CS, Weller j, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004;59(5):493–504. DOI: 10.1111/j.1365-2044.2004.03670.x
  15. Fasting S, Gisvold SE. Adverse drug errors in anaesthesia, and the impact of coloured syringe labels. Can J Anesth 2000;47(11):1060–1067. DOI: 10.1007/BF03027956
  16. Shultz J, Davies JM, Caird J, Chisholm S, Ruggles K, Puls R. Standardising anaesthesia medication drawers using human factors and quality assurance methods. Can J Anesth 2010;57(5):490–499. DOI: 10.1007/s12630-010-9274-8
  17. Jennings J, Foster J. Medication safety: Just a label away. AORN J 2007;86(4):618– 625. DOI: 10.1016/j.aorn.2007.04.003
  18. Webster C, Merry A, Gander P, Mann N. A prospective, randomised clinical evaluation of a new safety-oriented injectable drug administration system in comparison with conventional methods. Anaesthesia 2004;59:80–87. https://doi.org/10.1111/j.1365-2044.2004.03457.x 
  19. Paix AD, Bullock MF, Runciman WB, Williamson JA. Crisis management during anaesthesia: Problems associated with drug administration during anaesthesia. Qual Saf Health Care 2005;14(3):e15. DOI: 10.1136/qshc.2002.004119
  1. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC; 2019. www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  2. Lacourciere A, Kumar O, Apold S. Implementing an OR contact precautions decision algorithm to promote interprofessional teamwork for infection prevention. AORN J 2019;109(5):597–611. DOI: 10.1002/aorn.12667
  3. Russo PL, Stewardson AJ, Cheng C, Bucknall T, Mitchell B. The prevalence of healthcare associated infections among adult inpatients at nineteen large Australian acute-care public hospitals: A point prevalence survey. Antimicrob Resist Infect Control 2019;8(114). DOI: 10.1186/s13756-019-0570-y
  4. Victorian Department of Health. Patient-centred risk management strategy for multi-resistant organisms [Internet]. Melbourne: Victorian Department of Health; 2011 [cited 2020 February 5]. Available from: www2.health.vic.gov.au/Api/ downloadmedia/%7BA890DE96-921E-482F-97C6- 8390AFCB2310%7D
  5. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards. Sydney: ACSQHC; 2017.
  6. Australian Government. Therapeutic Goods (Charges) Act 1989. Canberra: Australian Government; 1989.
  7. Australian Government. Therapeutic Goods (Medical Devices) Regulations 2002. Canberra: Australian Government; 2002.
  8. Australian Government. Therapeutic Goods (Standard for Disinfectants and Sanitary Products) (TGO 104) Order 2019. Canberra: Australian Government; 2019.
  9. Therapeutic Goods Administration (TGA). Guidelines for the evaluation of sterilants and disinfectants [Internet]. Canberra: TGA;1998 [cited 2020 February 5].
  10. Therapeutic Goods Administration (TGA). Australian register of therapeutic goods. Canberra: TGA; 2019.
  11. Wood A. Updates to the AORN evidence rating model. AORN J 2019;110(1):5–8. DOI: 10.1002/aorn.12744
  12. Association of periOperative Registered Nurses (AORN). AORN guidelines for perioperative practice 2019. Denver, CO: AORN; 2019.
  13. Australian Commission on Safety and Quality in Health Care (ACSQHC). Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) – a guide for acute care health facilities [Internet]. Sydney: ACSQHC; 2017 [cited 2020 February 5]. Available from: www.safetyandquality.gov.au/our-work/ healthcare-associated-infection/cpe-guide
  14. Siegel J, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings, 2006 [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2006 [updated 2017, cited 2020 February 5]. Available from: www.cdc.gov/mrsa/pdf/ mdroGuideline2006.pdf
  15. Ong CW, Chen SC, Clark JE, Halliday CL, Kidd SE, Marriott DJ et al. Diagnosis, management and prevention of Candida auris in hospitals: Position statement of the Australasian Society for Infectious Diseases. Intern Med J 2019;49(10):1229–1243. DOI: 10.1111/imj.14612
  16. New South Wales Health. Candida auris infection considerations for the transfer or repatriation of an overseas patient to a NSW hospital [Internet]. Sydney: NSW Health; 2018 [cited 2020 February 5]. Available from: www.health.nsw.gov.au/sabs/Documents/2018- si-003.pdf
  17. Queensland Health. Guideline – infection prevention and control of Candida auris [Internet]. Brisbane: Queensland Health; 2019 [cited 2020 February 5]. Available from: www.health.qld.gov.au/__data/assets/ pdf_file/0028/722827/Candida-auris-guideline.pdf
  18. South Australia Health. Candida auris [Internet]. Adelaide: SA Health; 2019 [cited 2020 February 5]. Available from: www.sahealth.sa.gov.au/wps/ wcm/connect/public+content/sa+health+internet/ clinical+resources/clinical+topics/ healthcare+associated+infections/multidrug-resistant+organisms+mro/candida+auris
  19. Victorian Department of Health and Human Services (DHHS). Victorian guideline on Candida auris for health services [Internet]. Melbourne: DHHS; 2019 [cited 2020 February 5]. Available from: www2.health.vic.gov.au/ Api/downloadmedia/%7BE72DE677-88A3-4AF4-8557- C20DEA78638F%7D
  20. Ho C, Lau A, Cimon K, Farrah K, Gardam M. Screening, isolation, and decolonization strategies for vancomycin-resistant enterococci or extended spectrum beta-lactamase producing organisms: A systematic review of the clinical evidence and health services impact [Internet]. Ottawa; Canadian Agency for Drugs and Technology in Health; 2012 [cited 2020 February 5]. Available from: www.cadth.ca/media/pdf/ htis/sept-2012/RE0028_VREReport_e.pdf
  21. O’Hara LM, Calfee DP, Miller LG, Pineles L, Magder LS, Johnson JK et al. Optimizing contact precautions to curb the spread of antibiotic-resistant bacteria in hospitals: A multicenter cohort study to identify patient characteristics and healthcare personnel interactions associated with transmission of methicillin-resistant staphylococcus aureus. Clin Infect Dis 2019;69(Supplement_3):S171–S177. DOI: 10.1093/cid/ciz621
  22. Santiano N, Caldwell J, Ryan E, Smuts A, Schmidt HM. Knowledge and understanding of patients and health care workers about multi-resistant organisms. Healthc Infect 2014;19(2):45–52. https://doi.org/10.1071/HI13027
  23. Link T. Guideline implementation: Transmission-based precautions. AORN J 2019;110(6):637–649. DOI: 10.1002/aorn.12867
  24. Croke L. Appropriate environmental cleaning helps address threats from multidrug-resistant organisms. AORN J 2019;110(6):P5. DOI: 10.1002/aorn.12901
  25. Rutala WA, Weber DJ. Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach. Am J Infect Control 2019;47S(A96–A105). DOI: 10.1016/j.ajic.2019.01.014
  26. Department of Health Western Australia. Micro-alert codes utilised in Western Australian public healthcare facilities: Information for infection prevention and control staff [Internet]. Perth: Department of Health WA; 2019 [cited 2020 February 5]. Available from: https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Infectious%20diseases/PDF/HISWA/Microalert%20Codes%20Information%20for%20IPC%20Staff.pdf
  27. Public Health England. Guidance for the laboratory investigation, management and infection prevention and control for cases of Candida auris (C. auris) [Internet]. London: Public Health England; 2017 [cited February 5]. Available from: www.gov.uk/government/ publications/candida-auris-laboratory-investigation-management-and-infection-prevention-and-control
  28. National Institute for Communicable Diseases (NICD). Interim guidance for the management of Candida auris in South African hospitals [Internet]. Johannesburg: NICD; 2016 [cited 2020 February 5]. Available from: www.nicd.ac.za/wp-content/uploads/2017/03/2016- 12-22-InterimNICDRecommdtnsCAuris_NICDWebsite_ updated-header.pdf
  29. Toth DJA, Khader K, Beams A, Samore MH. Model-based assessment of the effect of contact precautions applied to surveillance-detected carriers of carbapenemase-producing enterobacteriaceae in long-term acute care hospitals. Clin Infect Dis 2019;69(Supplement_3):S206–S213. DOI: 10.1093/cid/ciz557
  30. Queensland Health. Management of multi-resistant organisms guideline. Brisbane: Queensland Government; 2017.
  31. Allen M, Hall L, Halton K, Graves N. Improving hospital environmental hygiene with the use of a targeted multi-modal bundle strategy. Infection, Disease & Health 2018;23(2):107–113. https://doi.org/10.1016/j.idh.2018.01.003
  32. Peters A, Otter J, Moldovan A, Parneix P, Voss A, Pittet D. Keeping hospitals clean and safe without breaking the bank; summary of the healthcare cleaning forum 2018. Antimicrob Resist Infect Control 2018;7(1):132. doi: 10.1186/s13756-018-0420-3
  33. Phan LT, Maita D, Mortiz DC, Bleasdale SC, Jones RM. Environmental contact and self-contact patterns of healthcare workers: Implications for infection prevention and control. Clin Infect Dis 2019;69(Supplement_3):S178–S184. DOI: 10.1093/cid/ciz558
  34. Mitchell BG, Farrington A, Allen M, Gardner A, Hall L, Barnett AG et al. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infection, Disease & Health 2017;22(4):195–202. DOI:https://doi.org/10.1016/j.idh.2017.08.001
  35. South Australia Health. Multi-resistant gram-negative micro-organisms: Infection prevention and control clinical guideline. Adelaide: SA Health; 2019.
  1. Maresca TA, Wikander N. Beyond testing and repairing instruments. Infection Control Today 2003 Apr [cited 2008 January 9]. Formerly available from: www.infectioncontroltoday.com/articles/341inside. html. 
  2. Therapeutic Goods Amendment (2016 Measures No. 1) Act 2017. 
  3. Burns L. Assessment of medical devices: How to conduct comparative technology evaluations of product performance. Int J Technol Assess Health Care 2007;23(4):455–463. DOI: 10.1017/S0266462307070547
  4. World Federation for Hospital Sterilisation Sciences (WFHSS). Recommendations by the quality task group: Deciding how to process a new medical device [Internet]. Luzern: WFHSS; 2006 [cited 2010 January 9]. Formerly available from: www.wfhss.com/html/educ/ qtg/qtg_0006_en.htm. 
  5. Olsen S. Safety in surgery: First steps towards a systems approach. Clinical Risk 2005;11(5):190–194. https://doi.org/10.1258/1356262054825920
  6. O’Connor M. Selecting and implementing surgical services information systems. Surgical Services Management 2000;6(5):522–528. 
  7. Davis JL, Knief S. A strategic approach to the introduction of new technology. Surgical Services Management 2003;9(4):426–429. 
  8. Brogmus G. Best practices in OR suite layout and equipment choices to reduce slips, trips and falls. AORN J 2007;86(3):384–394. DOI: 10.1016/j.aorn.2007.06.003
  9. Matern U. Safety hazards and ergonomics in the operating room. Surg Endosc 2007;21(11):1965–1969. DOI: 10.1007/s00464-007-9396-4
  10. Rosenthal K. Monitoring vital signs in vital times: Technical update. Nurs Manage 2002;33(3):47–48. DOI: 10.1097/00006247-200203000-00020
  1. Adedeji R, Oragui E, Khan W, Maruthainar N. The importance of correct patient positioning in theatres and implications of mal-positioning. J Perioper Pract 2010;20(4):143–147. DOI: 10.1177/175045891002000403
  2. Bowers M. Prone positioning for surgery. J Perioper Pract 2012;22(5):157–162. DOI: 10.1177/175045891202200504
  3. Akhavan A, Gainburg DM, Stock JA. Complications associated with patient positioning in urologic surgery. Urology 2010;76(6):1309–1316. DOI: 10.1016/j.urology.2010.02.060
  4. Ciasulli K, Heering A. Patient positioning in surgery: Trendelenburg position. CINAHL Nursing Guide. Glendale: CINAHL Information System, 2016. 
  5. Ellsworth WA, Basu CB, Iverson RE. Perioperative considerations for patient safety during cosmetic surgery – preventing complications. Can J Plast Surg 2009;17(1):9–16. PMID: 20190907 
  6. Spruce L, Van Wicklin SA. Back to basics: Positioning the patient. AORN J 2014;100(3):298–305 DOI: 10.1016/j.aorn.2014.06.004
  7. Aust H, Koehler S, Kuehnert M, Wiesmann T. Guideline– recommended 15° left lateral table tilt during cesarean section in regional anesthesia – practical aspects: An observational study. J Clin Anesth 2016 32:47–53. DOI: 10.1016/j.jclinane.2015.12.041
  8. Harvey NL, Hodgson RL, Kinsella SM. Does body mass index influence the degree of pelvic tilt produced by the Crawford wedge? Int J Obstet Anesth 2013;22:129–132. DOI: 10.1016/j.ijoa.2012.11.002
  9. Cluver C, Novilova N, Hofmeyr GJ, Hall DR. Maternal position during caesarean section for preventing maternal and neonatal complications. Cochrane Database Syst Rev 2013;3(3):CD007623. DOI: 10.1002/14651858.CD007623.pub3
  10. Chen HL, Chen XY, Wu J. The incidence of pressure ulcers in surgical patients of the last 5 years: A systematic review. Wounds 2012 24(9):234–241. 
  11. Connor T, Sledge JA, Bryant-Wiersema L, Stamm L, Potter P. Identification of pre-operative and intra-operative variables predictive of pressure ulcer development in patients undergoing urologic surgical procedures. Urol Nurs 2010;30(5):289–295.
  12. Codd RJ, Evans MD, Sagar PM, Williams GL. A systematic review of peripheral nerve injury following laparoscopic colorectal surgery. Colorectal Dis 2013;15(3):278–282. DOI: 10.1111/codi.12012
  13. O’Connor D, Radcliffe J. Patient positioning in anaesthesia. Anaesth Intensive Care Med 2015;16(11):543–547. https://doi.org/10.1016/j.mpaic.2015.08.008 
  14. Denholm B. Clinical issues: Tucking patients’ arms and general positioning. AORN J 2009;89(4):755–757. DOI: 10.1016/j.aorn.2009.03.010
  15. The Australian Commission on Safety and Quality in Health Care (ACSQHC). Comprehensive care standard [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 23]. Available from: www.safetyandquality.gov.au/ standards/nsqhs-standards/comprehensive-care-standard. 
  16. Chitlik A. Safe positioning for robotic- assisted laparoscopic prostatectomy. AORN J 2011 94(1):37–48. DOI: 10.1016/j.aorn.2011.02.012
  17. Bulfone G, Marzoli I, Quattrin R, Fabbro C, Palese A. A longitudinal study of the incidence of pressure sores and the associated risks and strategies adopted in Italian operating theatres. J Perioper Pract 2012;22(2):50–56. DOI: 10.1177/175045891202200202
  18. Spruce L. Back to basics: Preventing perioperative pressure injuries. AORN J 2017;105(1):92–99. DOI: 10.1016/j.aorn.2016.10.018
  19. Bennicoff G. Perioperative care of the morbidly obese patient in the lithotomy position. AORN J 2010;92(3):297–309. DOI: 10.1016/j.aorn.2010.04.016
  20. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards (second ed.) Sydney: ACSQHC; 2017. Available from: www. safetyandquality.gov.au/standards/nsqhs-standards. 
  21. Crook C. Advocacy: How far would you go to protect your patient. AORN J 2016;103(5):522–526. DOI: 10.1016/j.aorn.2016.03.009
  22. Poore SO, Sillah NM, Mahajan AY, Gutowski KA. Patient safety in the operating room: 1. Preoperative. Plast Reconstr Surg 2012;130(5):1038–1047. DOI: 10.1097/PRS.0b013e31826945d6
  23. Association of periOperative Registered Nurses (AORN). Positioning at a glance: Basic principles of patient positioning. AORN J 2016;103(3):10–12. https://doi.org/10.1016/S0001-2092(16)00139-3
  24. Engels D, Austin M, McNichol L, Fencl J. Pressure ulcers: Factors contributing to their development in the OR. AORN J 2016;103(3:)271–281. DOI: 10.1016/j.aorn.2016.01.008
  25. Primiano M, Friend M, McClure C, Nardi S, Fix L, Schafer M et al. Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN J 2011;94(6):555–566. DOI: 10.1016/j.aorn.2011.03.014
  26. Bedson R, Riccoboni A. Physiology of pregnancy: Clinical anaesthetic implications. Contin Educ Anaesth Crit Care Pain 2014;14(2):69–72. https://doi.org/10.1093/bjaceaccp/mkt036
  27. Vandse R, Cook M, Bergese S. Case report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery. F1000Res 2015;4:171. doi: 10.12688/f1000research.6659.2
  28. World Health Organization (WHO). Obesity [Internet]. Geneva: WHO; 2017 [cited 2020 March 23]. Available from: www.who.int/topics/obesity/en.
  29. World Health Organization (WHO). Obesity and overweight fact sheet [Internet]. Geneva: WHO; 2016 [cited 2020 March 23]. Available from: www.who.int/ mediacentre/factsheets/fs311/en. 
  30. Fencl JL, Walsh A. The bariatric patient: An overview of perioperative care. AORN J 2015;102(2):116–131. DOI: 10.1016/j.aorn.2015.05.007
  31. Wentzell J, Neff M. The weight is over: RN first assisting techniques for laparoscopic sleeve gastrectomy. AORN J 2015;102(2):162–180. DOI: 10.1016/j.aorn.2015.05.019
  32. Australian Institute of Health and Welfare (AIHW). Older Australia at a glance [Internet]. Canberra: AIHW; 2018 [cited 2020 March 23]. Available from: www.aihw.gov.au/ reports/older-people/older-australia-at-a-glance/ contents/health-and-functioning/health-and-disability-status. 
  33. Oster KA, Oster CA. Special needs population: Care of the geriatric patient population in the perioperative setting. AORN J 2015;101(4):443–459. DOI: 10.1016/j.aorn.2014.10.022
  34. Hortman C, Chung S. Positioning considerations in robotic surgery. AORN J 2015;102(4):434–440. DOI: 10.1016/j.aorn.2015.07.008
  35. Sutton S, Link T, Makic MBF. A quality improvement project for safe and effective patient positioning during robot-assisted surgery. AORN J 2013;97(4):448–456. DOI: 10.1016/j.aorn.2013.01.014
  36. Ghomi A, Kramer C, Askari R, Chavan NR, Einarsson JI. Trendelenburg position in gynecologic robotic-assisted surgery. J Minim Invas Gynecol 2012;19(4):485–489. DOI: 10.1016/j.jmig.2012.03.019
  37. Mills JT, Burris MB, Warburton DJ, Conaway MR, Schenkman NS, Krupskit TL. Positioning injuries associated with robotic assisted urological surgery. J Urol 2013;190:580–584. DOI: 10.1016/j.juro.2013.02.3185
  38. Mangham M. Positioning of the anaesthetised patient during robotically assisted laparoscopic surgery: Perioperative staff experience. J Perioper Pract 2015;26(3):50–52. https://doi.org/10.1177/175045891602600305  
  39. Klauschie J, Wechter ME, Jacob K, Zanagnolo V, Montero R, Magrina J et al. Use of anti-skid material and patient positioning to prevent patient shifting during robotic-assisted gynecologic procedures. J Minim Invas Gynecol 2010;17(4):504–507. DOI: 10.1016/j.jmig.2010.03.013
  40. DiPierro GB, Wirth JG, Ferrari M, Danuser H, Matteri A. Impact of a single-surgeon learning curve on complications, positioning injuries, and renal function in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection. Urology 2014;84(5):1106–1111. DOI: 10.1016/j.urology.2014.06.047
  41. National Pressure Ulcer Advisory Panel (NPUAP). Prevention and treatment of pressure ulcers: Quick reference [Internet]. Washington: NPUAP; 2016 [cited 2017 December 7]. Formerly available from: www.npuap. org/wp-content/uploads/2014/08/Quick-Reference- Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf. 
  42. Strasser LA. Improving skin integrity in the perioperative environment using an evidence-based protocol. J Dermatol Nurses Assoc 2012;4(6);351–360. doi: 10.1097/JDN.0b013e318274b46c
  43. Fred C, Ford S, Wagner D, Vanbrackle L. Intraoperatively acquired pressure ulcers and perioperative normothermia: A look at relationships. AORN J 2012;96(3):251–260. DOI: 10.1016/j.aorn.2012.06.014
  44. Scott SM. Progress and challenges in perioperative pressure ulcer prevention. J Wound Ostomy Continence Nurs 2015;42(5):480–485. DOI: 10.1097/WON.0000000000000161
  45. Huang HY, Chen HL, Xu XY. Pressure redistribution surfaces for presentation of surgery-related pressure ulcers: A meta-analysis. Ostomy Wound Manage 2013;59(4):36–48. 
  46. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards [Internet]. Sydney: ACSQHC; 2017. Available at www.safetyandquality.gov.au/standards/ nsqhs-standards. 
  47. Schoonhoven L, Defloor T, Grypdonck MH. Incidence of pressure ulcers due to surgery. J Clin Nurs 2002;11(4):479–487. DOI: 10.1046/j.1365-2702.2002.00621.x
  48. Criscitelli T. Caring for patients with chronic wounds: Safety considerations during the surgical experience. AORN J 2016;104(1):67–70. DOI: 10.1016/j.aorn.2016.05.002
  49. Rahman MA. Perioperative Setting: Manual Handling. Adelaide: The Joanna Briggs Institute, 2016.

 

 

 

  1. Ritter MA. Operating room environment. Clin Orthop Relat Res 1999;(369):103–109. DOI: 10.1097/00003086-199912000-00011
  2. Gosden PE, MacGowan AP, Bannister GC. Importance of air quality and related factors in the prevention of infection in orthopaedic implant surgery. J Hosp Infect 1998;39(3):173–180. DOI: 10.1016/s0195-6701(98)90255-9
  3. Memarzadeh F, Manning A. Comparison of operating room ventilation systems in the protection of the surgical site. ASHRAE Transactions 2002;108(2):13. 
  4. Robbins CR. Chemical composition of different hair types. In: Robbins CR. Chemical and Physical Behavior of Human Hair, pp. 105–176. Berlin: Springer; 2012. DOI: 10.1007/978-3-642-25611-0_2.  
  5. Wilson M. The indigenous microbiota of the skin. In: Wilson M. Bacteriology of Humans: An Ecological Perspective, pp. 56–94. London: Blackwell Publishing; 2008. 
  6. Sherertz RJ, Bassetti S, Bassetti-Wyss B. ‘Cloud’ health-care workers. Emerg Infect Dis 2001; 7(2):241–244.DOI: 10.3201/eid0702.010218
  7. Sherertz RJ, Reagan DR, Hampton KD, Robertson KL, Streed SA, Hoen HM et al. A cloud adult: the Staphylococcus aureus-virus interaction revisited. Ann Intern Med 1996;124(6):539–547. DOI: 10.7326/0003-4819-124-6-199603150-00001
  8. Rijnders M, Nys S, Driessen C, Hoebe CJ, Hopstaken RM, Oudhuis GJ et al. Staphylococcus aureus carriage among GPs in The Netherlands. Br J Gen Pract 2010;60(581):902–906. DOI: 10.3399/bjgp10X544078
  9. Blok HE, Troelstra A, Kamp-Hopmans TE, Gigengack- Baars AC, Vandenbroucke-Grauls CM, Weersink AJ et al. Role of healthcare workers in outbreaks of methicillin-resistant Staphylococcus aureus: A 10- year evaluation from a Dutch university hospital. Infect Control Hosp Epidemiol 2003;24(9):679–685. DOI: 10.1086/502275
  10. Lin YC, Lauderdale TL, Lin HM, Chen PC, Cheng MF, Hsieh KS et al. An outbreak of methicillin-resistant Staphylococcus aureus infection in patients of a pediatric intensive care unit and high carriage rate among health care workers. J Microbiol Immunol Infect 2007;40(4):325–334. 
  11. Olsen K, Sangvik M, Simonsen GS, Sollid JU, Sundsfjord A, Thune I et al. Prevalence and population structure of Staphylococcus aureus nasal carriage in healthcare workers in a general population. The Tromso Staph and Skin Study. Epidemiol Infect 2013;141(1):143–152. DOI: 10.1017/S0950268812000465
  12. Schwarzkopf R, Takemoto RC, Immerman I, Slover JD, Bosco JA. Prevalence of Staphylococcus aureus colonization in orthopaedic surgeons and their patients: A prospective cohort controlled study. J Bone Joint Surg Am 2010;92(9):1815–1819. DOI: 10.2106/JBJS.I.00991
  13. Clark RP, De Calcina-Goff ML. Some aspects of the airborne transmission of infection. J R Soc Interface 2009;6(6 Suppl. 6):S767–782. DOI: 10.1098/rsif.2009.0236.focus
  14. Standards Australia. AS 3789.3:1994. Textiles for health care facilities and institutions. Part 3: Apparel for operating theatre staff [Internet]. Sydney: Standards Australia; 1994 [cited 2014 February 18].
  15. Standards Australia / Standards New Zealand. AS/ NZS 4146:2000. Laundry practice [Internet]. Sydney: Standards Australia; 2000 [cited 2014 February 18]. Available from: www.saiglobal.com
  16. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standard 3: Preventing and controlling healthcare associated infections [Internet]. Sydney: ACSQHC; 2017 [cited 2020 March 2]. Available from: www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare-associated-infection-standard
  17. Australian and New Zealand College of Anaesthetists (ANZCA). PS28 Guidelines on infection control in anaesthesia. Melbourne: ANZCA, 2015. 
  18. Centers for Disease Control and Prevention (CDC). Bacterial meningitis after intrapartum spinal anesthesia – New York and Ohio, 2008–2009. MMWR Morb Mort Wkly Rep 2010;59(3):65–69. 
  19. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20(4):250–278.DOI: 10.1086/501620
  20. Thurston A. Sacred rituals in the operating theatre: Summarising the science. Curr Orthop 2004;18(2):135– 146. DOI:https://doi.org/10.1016/j.cuor.2004.02.006
  21. Mailhot CB, Slezak LG, Copp G, Binger JL. Cover gowns. Researching their effectiveness. AORN J 1987;46(3):482–490. DOI: 10.1016/s0001-2092(07)66459-x
  22. Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. What’s hanging around your neck? Pathogenic bacteria on identity badges and lanyards. Med J Aust 2008;188(1):5–8.https://doi.org/10.5694/j.1326-5377.2008.tb01494.x
  23. Alexander R, Volpe NG, Catchpole C, Allen R, Cope S. Are lanyards a risk for nosocomial transmission of potentially pathogenic bacteria? J Hosp Infect 2008;70(1):92–93.DOI: 10.1016/j.jhin.2008.05.022
  24. Baird C, Nunn T, Gregori A. Inadequate standards of hygiene in an operating theatre changing room. J Hosp Infect 2005;59(3):268–269.DOI: 10.1016/j.jhin.2004.09.024
  25. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6(1):130–138. DOI: 10.1186/1471-2334-6-130
  26. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol 2000;38(2):724–726. DOI: 10.1128/JCM.38.2.724-726.2000  
  27. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol 2001;39(9):3360–3361.  doi: 10.1128/JCM.39.9.3360-3361.2001
  28. Copp G, Mailhot CB, Zalar M, Slezak L, Copp AJ. Covergowns and the control of operating room contamination. Nurs Res 1986;35(5):263–268. 
  29. Roxburgh M, Gall P, Lee K. A cover up? Potential risks of wearing theatre clothing outside theatre. J Perioper Pract 2006;16(1):30–41.DOI: 10.1177/175045890601600104
  30. Kaplan C, Mendiola R, Ndjatou V, Chapnick E, Minkoff H. The role of covering gowns in reducing rates of bacterial contamination of scrub suits. Am J Obstet Gynecol 2003;188(5):1154–1155.DOI: 10.1067/mob.2003.296
  31. Edwards RD, Saladyga AT, Schriver JP, Davis KG. Patient attitudes to surgeons’ attire in an outpatient clinic setting: Substance over style. Am J Surg 2012;204(5):663–665.DOI: 10.1016/j.amjsurg.2009.09.001
  32. Landry M, Dornelles AC, Hayek G, Deichmann RE. Patient preferences for doctor attire: The white coat’s place in the medical profession. Ochsner J 2013;13(3):334–342. 
  33. Gooden BR, Smith MJ, Tattersall SJ, Stockler MR. Hospitalised patients’ views on doctors and white coats. Med J Aust 2001;175(4):219–222. 
  34. Major K, Hayase Y, Balderrama D, Lefor AT. Attitudes regarding surgeons’ attire. Am J Surg 2005;190(1):103– 106.DOI: 10.1016/j.amjsurg.2005.04.003
  35. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118(11):1279–1286. DOI: 10.1016/j.amjmed.2005.04.026
  36. Williams G, Jarvis N. The emperor’s new clothes: Workwear and uniforms guidelines undressed. Br J Hosp Med (Lond) 2009;70(8):456–458. DOI: 10.12968/hmed.2009.70.8.43538
  37. Loveday HP, Wilson JA, Hoffman PN, Pratt RJ. Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: An evidence review. Br J Infect Contr 2007;8(4):10–21.https://doi.org/10.1177/1469044607082078 
  38. Fitzgerald RH Jr. Microbiologic environment of the conventional operating room. Arch Surg 1979;114(7):772–775.DOI: 10.1001/archsurg.1979.01370310014003
  39. Knobben BAS, van Horn JR, van der Mei HC, Busscher HJ. Evaluation of measures to decrease intraoperative bacterial contamination in orthopaedic implant surgery. J Hosp Infect 2006;62(2):174–180.DOI: 10.1016/j.jhin.2005.08.007
  40. Owers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theatres. J Hosp Infect 2004;58(3):230–232.DOI: 10.1016/j.jhin.2004.06.028
  41. Ritter MA, Marmion P. The exogenous sources and controls of microorganisms in the operating room. Orthop Nurs 1988;7(4):23–28.DOI: 10.1097/00006416-198807000-00008
  42. Rahav G, Pitlik S, Amitai Z, Lavy A, Blech M, Keller N et al. An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants. Clin Infect Dis 2006;43(7):823–30. DOI: 10.1086/507535
  43. McHugh SM, Corrigan MA, Hill ADK, Humphreys H. Surgical attire, practices and their perception in the prevention of surgical site infection. Surgeon 2014;12(1):47–52.DOI: 10.1016/j.surge.2013.10.006
  44. Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol 2011;9(4):244–253. DOI: 10.1038/nrmicro2537. DOI: 10.1038/nrmicro2537
  45. Standards Australia. AS ISO 13485:2017. Medical devices – Quality management systems – Requirements for regulatory purposes [Internet]. Sydney: Standards Australia; 2017 [cited 2020 March 2]. Available from: www.saiglobal.com. 
  46. Alexander JW, Van Sweringen H, Vanoss K, Hooker EA, Edwards MJ. Surveillance of bacterial colonization in operating rooms. Surg Infect (Larchmt) 2013;14(4):345– 351.DOI: 10.1089/sur.2012.134
  47. Standards Australia. AS/NZS ISO 9001:2016. Quality management systems – Requirements. Sydney: Standards Australia; 2016 [cited 2020 March 2]. Available from: www.saiglobal.com
  48. French MLV, Ritter MA, Hart JB, Eitzen HE. A systems analysis approach to post-operative wound infections. Phase II. A microbiological assessment of the exogenous bacterial controls in the operating room. Cleve Clin Q 1973;40(4):221–227.DOI: 10.3949/ccjm.40.4.221
  49. Sanzen L, Carlsson AS, Walder M. Air contamination during total hip arthroplasty in an ultraclean air enclosure using different types of staff clothing. J Arthroplasty 1990;5(2):127–130. DOI: 10.1016/s0883-5403(06)80231-7
  50. Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: Effect on airborne contamination. Infect Control Hosp Epidemiol 2002;23(4):218–220.DOI: 10.1086/502040
  51. Leonas KK. Effect of laundering on the barrier properties of reusable surgical gown fabrics. Am J Infect Control 1998;26(5):495–501.DOI: 10.1016/s0196-6553(98)70022-7
  52. Standards Australia / Standards New Zealand. AS/ NZS 1957:1998. Textiles – Care labelling [Internet]. Sydney: Standards Australia; 1998 [cited 2020 March 2]. Available from: www.saiglobal.com
  53. Braswell ML, Spruce L. Implementing AORN recommended practices for surgical attire. AORN J 2012;95(1):122–140.DOI: 10.1016/j.aorn.2011.10.017
  54. Al-Benna S. Laundering of theatre scrubs at home. J Perioper Pract 2010;20(11):392–396.DOI: 10.1177/175045891002001101
  55. Standards Australia / Standards New Zealand. AS/NZS 2210.1:2010 Safety, protective and occupational footwear. Part 1: Guide to selection, care and use [Internet]. Sydney: Standards Australia; 2010 [cited 2014 February 18]. Available from: www.saiglobal.com
  56. Agarwal M, Hamilton-Stewart P, Dixon RA. Contaminated operating room boots: The potential for infection. Am J Infect Control 2002;30(3):179–183. DOI: 10.1067/mic.2002.119513
  57. Summers PR, Biswas MK, Portera SG, Moore L. Blood-saturated operating-room shoe covers. West J Med 1992;157(2):184–185. 
  58. World Health Organization (WHO). WHO Guidelines for safe surgery: Safe surgery saves lives [Internet]. Geneva: World Health Organization; 2009 [cited 2014 February 20]. Available from https://apps.who.int/iris/handle/10665/44185
  59. Siegel J, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings [Internet]. Atlanta: Centers for Disease Control and Prevention; 2007 [cited 2014 February 20]. Available from: www.cdc.gov/ncidod/ dhqp/pdf/isolation2007.pdf
  60. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JAW. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth 1992;69(4):407– 408.DOI: 10.1093/bja/69.4.407
  61. Phillips WJ. Gesundheit! Catheter Cardiovasc Interv 2004; 63(2):255–256.DOI: 10.1002/ccd.20163
  62. Tang JW, Liebner TJ, Craven BA, Settles GS. A schlieren optical study of the human cough with and without wearing masks for aerosol infection control. J R Soc Interface 2009;6(Supp. 6):S727–736.DOI: 10.1098/rsif.2009.0295.focus
  63. Tang JW, Nicolle ADG, Pantelic J, Jiang M, Sekhr C, Cheong DKW et al. Qualitative real-time schlieren and shadowgraph imaging of human exhaled airflows: An aid to aerosol infection control. PLoS ONE 2011;6(6). DOI:10.1371/journal.pone.0021392. DOI: 10.1371/journal.pone.0021392
  64. Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev 2002(1):CD002929. DOI:10.1002/14651858.CD002929.  
  65. McLure HA, Talboys CA, Yentis SM, Azadian BS. Surgical face masks and downward dispersal of bacteria. Anaesthesia 1998;53(7):624–626.DOI: 10.1046/j.1365-2044.1998.435-az0528.x
  66. McLure HA, Mannam M, Talboys CA, Azadian BS, Yentis SM. The effect of facial hair and sex on the dispersal of bacteria below a masked subject. Anaesthesia 2000; 55(2):173–176.DOI: 10.1046/j.1365-2044.2000.055002173.x
  67. Standards Australia. AS 4381:2015 Single-use face masks for use in health care[Internet]. Sydney: Standards Australia: 2015 [cited 2020 March 2]. Available from: www.saiglobal.com
  68. Arrowsmith VA, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database Syst Rev 2012(5):CD003325. https://doi.org/10.1002/14651858.CD003325.pub3
  69. Fagernes M, Lingaas E. Impact of finger rings on transmission of bacteria during hand contact. Infect Control Hosp Epidemiol 2009;30(5):427–432.DOI: 10.1086/596771
  70. Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA. Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol 2000;21(8):505–509. DOI: 10.1086/501794
  71. McNeil SA, Nordstrom-Lerner L, Malani PN, Zervos M, Kauffman CA. Outbreak of sternal surgical site infections due to Pseudomonas aeruginosa traced to a scrub nurse with onychomycosis. Clin Infect Dis 2001;33(3):317–323.DOI: 10.1086/321890
  72. Moolenaar RL, Crutcher JM, San Joaquin VH, Sewell LV, Hutwagner LC, Carson LA et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 2000;21(2):80–85.DOI: 10.1086/501739
  73. Passaro DJ, Waring L, Armstrong R, Bolding F, Bouvier B, Rosenberg J et al. Post-operative Serratia marcescens wound infections traced to an out-of-hospital source. J Infect Dis 1997;175(4):992–995.DOI: 10.1086/514008
  74. Gordin FM, Schultz ME, Huber R, Zubairi S, Stock F, Kariyil J. A cluster of hemodialysis-related bacteremia linked to artificial fingernails. Infect Control Hosp Epidemiol 2007;28(6):743–744. DOI: 10.1086/517977
  75. Gupta A, Della-Latta P, Todd B, San Gabriel P, Haas J, Wu F et al. Outbreak of extended-spectrum betalactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol 2004;25(3):210–215.DOI: https://doi.org/10.1086/502380 
  76. Parry MF, Grant B, Yukna M, Adler-Klein D, McLeod GX, Taddonio R et al. Candida osteomyelitis and diskitis after spinal surgery: An outbreak that implicates artificial nail use. Clin Infect Dis 2001;32(3):352–357.DOI: 10.1086/318487
  77. Fagernes M, Lingaas E. Factors interfering with the microflora on hand: A regression analysis of samples from 465 healthcare workers. J Adv Nurs 2010;67(2):297–307.DOI: 10.1111/j.1365-2648.2010.05462.x
  78. Guin JD, Baas K, Nelson-Adesokan P. Contact sensitization to cyanoacrylate adhesive as a cause of severe onychodystrophy. Int J Dermatol 1998;37(1):31– 36.DOI: 10.1046/j.1365-4362.1998.00252.x
  79. Toles A. Artificial nails: Are they putting patients at risk? A review of the research. J Pediatr Oncol Nurs 2002;19(5):164–171.DOI: 10.1016/s1043-4542(02)00009-7
  80. Messano GA. Bacterial and fungal contamination of dental hygienists’ hands with and without finger rings. Acta Stomatologica Naissi 2013;29(67):1260–1264.doi: 10.5937/asn1367260M
  81. Bartlett GE, Pollard TCB, Bowker KE, Bannister GC. Effect of jewellery on surface bacterial counts of operating theatres. J Hosp Infect 2002;52(1):68–70.DOI: 10.1053/jhin.2002.1250
  82. Guiard-Schmid JB, Picard H, Slama L, Maslo C, Amiel C, Pialoux G et al. Piercing and infectious complications: An important public health issue in France (Le piercing et ses complications infectieuses un enjeu de sante publique en France) – article in French. Presse Med 2000; 29(35):1948–1956. 
  83. Holbrook J, Minocha J, Laumann A. Body piercing: Complications and prevention of health risks. Am J Clin Dermatol 2012;13(1):1–17. DOI: 10.2165/11593220-000000000-00000
  84. Butt U, Saleem U, Yousuf K, El-Bouni T, Chambler A, Eid AS. Infection risk from surgeons’ eyeglasses. J Orthop Surg (Hong Kong) 2012;20(1):75–77.DOI: 10.1177/230949901202000115
  85. Weiner BK, Kilgore WB. Bacterial shedding in common spine surgical procedures: Headlamp/loupes and the operative microscope. Spine 2007;32(8):918–920.DOI: 10.1097/01.brs.0000259837.54411.60
  86. Trick WE, Vernon MO, Hayes RA, Nathan C, Rice TW, Peterson BJ et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis 2003;36(11):1383– 1190. DOI: 10.1086/374852
  87. Sebold EJ, Jordan LR. Intraoperative glove perforation: A comparative analysis. Clin Orthop Relat Res 1993;(297):242–244. 
  88. Fejjal N, Belmir R, El Mazouz S, Gharib NE, Abbassi A, Belmahi AM. Finger avulsion injuries: A report of four cases. Indian J Orthop 2008;42(2):208–211. DOI: 10.4103/0019-5413.40259
  89. Brooks D, Buntic RF, Kind GM, Schott K, Buncke GM, Buncke HJ. Ring avulsion: Injury pattern, treatment and outcome. Clin Plast Surg 2007;34(2):187–195. DOI: 10.1016/j.cps.2006.11.001
  90. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 2]. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  91. Korniewicz D, El-Masri. Exploring the benefits of double gloving during surgery. AORN J 2012;95(3):328– 336.DOI: 10.1016/j.aorn.2011.04.027
  92. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev 2006(3):CD003087. DOI: 10.1002/14651858.CD003087.pub2
  93. Laing RM. Protection provided by clothing and textiles against potential hazards in the operating theatre. Int J Occup Saf Ergon 2008;14(1):107–115.DOI: 10.1080/10803548.2008.11076753
  94. Marasco S, Woods S. The risk of eye splash injuries in surgery. Aust N Z J Surg 1998;68(11):785–787. DOI: 10.1111/j.1445-2197.1998.tb04677.x
  95. Merollini KM, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: Guideline recommendations and expert opinion. Am J Infect Control 2013;41(3):221– 226. https://doi.org/10.1016/j.ajic.2012.03.027
  96. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458–1465. DOI: 10.1001/jama.282.15.1458
  97. Gurses AP, Murphy DJ, Martinez EA, Berenholtz SM, Pronovost PJ. A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines. Jt Comm J Qual Patient Saf 2009;35(10):526–532,485. DOI: 10.1016/s1553-7250(09)35072-2
  98. Neo F, Edward KL, Mills C. Current evidence regarding non-compliance with personal protective equipment – an integrative review to illuminate implications for nursing practice. ACORN J 2012;25(4):22–30.
  1. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 2]. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019
  2. Cesario SK. Designing health care environments: Part I. Basic concepts, principles, and issues related to evidence-based design. J Contin Educ Nurs 2009;40(6):280–288.DOI: 10.3928/00220124-20090522-09
  3. American Society of Anesthesiologists (ASA). Operating Room Design Manual, 2010–2011 [Internet]. Washington: ASA; 2011 [cited 2014 February 18] Available from: www. asahq.org
  4. Australasian Health Infrastructure Alliance (AHIA). Australasian health facility guidelines 2016 [Internet]. Canberra: AHIA; 2011 [cited 2020 March 23] Available from: www.healthfacilityguidelines.com.au/full-guidelines
  5. Standards Australia. AS 4485.1:1997. Security for health care facilities – General requirements [Internet]. Sydney: Standards Australia; 1997 [cited 2020 March 23]. Available from: www.saiglobal.com
  6. Standards Australia. AS 4485.2:1997. Security for health care facilities – Procedures guide [Internet]. Sydney: Standards Australia; 1997 [cited 2020 March 23]. Available from: www.saiglobal.com
  7. Stanfill Edens P. Workplace reengineering, reorganization, and redesign. In: Gullate MM (ed). Nursing Management: Principles and Practice [Internet]. Pittsburgh: Oncology Nursing Society; 2005 [cited 2020 March 23]. Available from: www.medscape.com/viewarticle/511808_10
  8. Forcht Dagi T, Schecter W. Preparation of the operating room. In: American College of Surgeons ACS Surgery: Principles and Practice. New York: BC Decker Inc.; 2008. 
  9. Victorian Department of Health. Hospital capital planning module [Internet]. Melbourne: Department of Health; 2010[cited 2014 February 18]. Formerly available from: www.capital.dhs.vic. gov.au/capdev/ProjectProposals/Benchmarking/ HospitalCapitalModule
  10. Queensland Health. Capital infrastructure minimum requirements (CIMR) (v4.0) [Internet]. Brisbane: Queensland Health; 2012 [cited 2014 February 18]. Formerly available from: www.health.qld.gov.au/chrisp/ resources/capital_works.asp. 
  11. Australian and New Zealand College of Anaesthetists (ANZCA). PS04 2018 Statement on the post-anaesthesia care unit [Internet]. Melbourne: ANZCA; 2020 [cited 2020 June 3]. Available from:http://www.anzca.edu.au/Documents/ps04-2006-recommendations-for-the-post-anaesthesia.pdf
  12. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures [Internet]. Melbourne: ANZCA; 2018 [cited 2020 March 23]. Available from: http://www.anzca.edu.au/Documents/ps15-2010-recommendations-for-the-perioperative-ca.pdf
  13. Australian and New Zealand College of Anaesthetists (ANZCA). PS55 2012. Recommendations on minimum facilities for safe administration of anaesthesia in operating suites and other anaesthetising locations [Internet]. Melbourne: ANZCA; 2012 [cited 2020 March 23]. Available from: http://www.anzca.edu.au/Documents/ps55-2012-recommendations-on-minimum-facilities-fo.pdf
  14. Standards Australia / Standards New Zealand. AS/ NZS 3003:2018. Electrical installations – Patient areas [Internet]. Sydney: Standards Australia; 2018 [cited 2020 March 23]. Available from: www.saiglobal.com
  15. Standards Australia / Standards New Zealand. AS/ NZS 4187:2014. Reprocessing of reusable medical devices in health service organizations (Incorporating Amendment Nos 1 and 2) [Internet]. Sydney: Standards Australia; 2014 [cited 2020 March 23]. Available from: www.saiglobal.com
  16. Standards Australia. HB260–2003. Handbook. Hospital acquired infections – Engineering down the risk, 6.10 – Operating rooms [Internet]. Sydney: Standards Australia; 2003 [cited 2020 March 23]. Available from: www.saiglobal.com
  17. Loddon Mallee Region Infection Control Resource Centre. Infection control principles for the management of construction, renovation, repairs and maintenance within health care facilities: A manual for reducing the risk of health care associated infection by dust and water borne microorganisms. 2nd ed. [Internet]. Bendigo: Loddon Mallee Region Infection Control Resource Centre; 2005 [cited 2020 March 23]. Available from: www.scribd.com/document/125996572/ Australian-Infection-Control-Manual-2nd-Edition-pdf
  18. Standards Australia / Standards New Zealand. AS/NZS 1668.2:2012. The use of ventilation and airconditioning in buildings. Part 2 Mechanical ventilation in buildings [Internet]. Sydney: Standards Australia; 2012 [cited 2020 March 23]. Available from: www.saiglobal.com
  19. Ulrich R, Zimring C, Quan AJ, Choudhary R. The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity. Report to the center for health design for the designing the 21st century hospital project [Internet]. Concord CA: The Center for Health Design; 2004 [cited 2020 March 23]. Available from: www.healthdesign.org/chd/research/ role-physical-environment-hospital-21st-century
  20. World Health Design. Working environments: Operating room architecture and design and the effects on staff morale [Internet]. Brisbane: World Health Design; 2013. Formerly available from: www.worldhealthdesign.com/ Operating-room-architecture.aspx. 
  21. Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standard 3–Preventing and controlling healthcare associated infections [Internet]. Sydney: ACSQHC, 2017 [cited 2020 March 23]. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare-associated-infection-standard
  22. Standards Australia / Standards New Zealand. AS/ NZS 2500:2004. Guide to the safe use of electricity in patient care [Internet]. Sydney: Standards Australia; 2004 [cited 2020 March 23]. Available from: www.saiglobal.com
  23. Napoli C, Marcotrigiano V, Montagna MT. Air sampling procedures to evaluate microbial contamination: A comparison between active and passive methods in operating theatres. BMC Public Health 2012;12:594 [cited 2020 March 23]. DOI: 10.1186/1471-2458-12-594 Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-594
  24. Berry K. Operating room architecture and the effects on morale. ACORN J 2008;21(2):6–13. 
  25. Hoffman PN, Williams J, Stacey A, Bennett AM, Ridgway GL, Dobson C et al. Microbiological commissioning and monitoring of operating theatre suites. A report of a working party of the Hospital Infection Society. J Hosp Infect 2002;52(1):1–28. https://doi.org/10.1053/jhin.2002.1237
  26. Government of Western Australia Department of Health. Operational Directive 0610/15. Microbiological air sampling of operating rooms in Western Australian Healthcare Facilities. Perth: WA Department of Health; 2015 [cited 2020 March 23]. Available from: ww2.health. wa.gov.au/About-us/Policy-frameworks/Public- Health/Mandatory-requirements/Communicable- Disease-Control/Infection-Prevention-and-Control/ Microbiological-Air-Sampling-of-Operating-Rooms-in- Western-Australian-Healthcare-Facilities
  27. State Government of Victoria Department of Health. Commissioning of facilities [Internet]. Melbourne: Victorian Department of Health; 2010 [cited 2014 February]. Formerly available from: www.capital.dhs.vic. gov.au/capdev/CommissioningFacilities
  1. McEwin JA. Equipment preparation [Internet]. Vancouver: Tourniquets.org; 2017 [cited 2020 March 24]. Available from: tourniquets.org/equipment-preparation/
  2. ECRI Institute. Inappropriate use of oxygen to inflate or power medical devices. ECRI Institute Medical Device Safety Reports 1982 [Internet]. Philadelphia: ECRI Institute: 1982 [cited 2020 March 24]. Available from: www.mdsr.ecri.org/summary/detail.aspx?doc_id=8122  
  3. Olivecrona C, Tidermark J, Hamberg P, Ponzer S, Cederjall C. Skin protection underneath the pneumatic tourniquet during total knee arthroplasty: A randomized controlled trial of 92 patients [Internet]. Acta Orthop 2006 [cited 2020 March 24]. Available from: tourniquets.org/wp-content/uploads/PDFs/ Olivecrona-Skin-protection-underneath-the-pneumatic-tourniquet-Olivecrona-2006.pdf  
  4. Tuncali B, Karci A, Bacakoglu AK, Tuncali BE, Ekin A. Controlled hypotension and minimal inflation pressure: A new approach for pneumatic tourniquet application in upper limb surgery. Anesth Analg 2003;97(5):1529–1532. DOI: 10.1213/01.ane.0000081660.97731.91
  5. Estebe JP, Le Naoures A, Chemaly L, Ecoffey C. Tourniquet pain in a volunteer study: Effect of changes in cuff width and pressure. Anaesthesia 2000;55(1):21– 26.DOI: 10.1046/j.1365-2044.2000.01128.x
  6. Hirota K, Hashimoto H, Kabara S, Tsubo T, Sato Y, Ishihara H et al. The relationship between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic surgeries. Anesth Analg 2001;93(3):776–780. DOI: 10.1097/00000539-200109000-00044
  7. Lu C, Chen Y, Wang M. Massive pulmonary embolism after application of an Esmarch bandage. Anesth Analg 2004;98(4):1187–1189. DOI: 10.1213/01.ane.0000104583.77388.02
  8. Sanders BJ, D’Alessio JG, Jernigan JR. Intraoperative hypothermia associated with lower extremity tourniquet deflation. J Clin Anesth 1996;8(6):504–507. DOI: 10.1016/0952-8180(96)00114-6
  9. Horlocker TT, Hebl JR, Gali B, Janowski CJ, Burkle CM, Berry DJ et al. Anaesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 2006;102(3):950–955.DOI: 10.1213/01.ane.0000194875.05587.7e
  10. Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. Pediatric tourniquets: Analysis of cuff and limb interface, current practice and guidelines for use. J Pediatr Orthop 2001;21(5):671–676. 
  11. Walsh EF, Ben-David D, Ritter M, Mechrefe AP, Mermel LA, DiGiovanni CW. Microbial colonization of tourniquets used in orthopaedic surgery. Orthopedics 2006;29:709. DOI: 10.3928/01477447-20060801-08
  1. Organ and Tissue Authority (OTA). Organ and Tissue Authority 2018-19 Annual Report [Internet]. Canberra: AOTDTA; 2019 [cited 2020 April 1]. Available from: https://donatelife.gov.au/about-us/strategy-and-performance/annual-report-0
  2. DonateLife Australia. Facts and statistics [Internet]. Canberra: Australian Organ and Tissue Authority; 2015 [cited 2015 August 13]. Available from: www.donatelife. gov.au/discover/facts-and-statistics
  3. Australian and New Zealand Organ Donation (ANZOD) Registry. Monthly report on deceased organ donation in Australia March 2020 [Internet]. Adelaide: ANZOD; 2020 [cited 2020 April 1]. Available from: www.anzdata. org.au/publications-2/ monthly-summaries
  4. Australian and New Zealand Intensive Care Society (ANZICS). The Statement on Death and Organ Donation 4th ed. [Internet]. Melbourne: ANZICS; 2019 [cited 2020 April 1]. Available from: www.anzics.com.au/ wp-content/uploads/2020/01/ANZICS-Statement-on- Death-and-Organ-Donation-Edition-4.pdf
  5. Australian Organ and Tissue Donation Transplantation Authority (AOTDTA). National protocol for donation after cardiac death (DCD) [Internet]. Canberra: AOTDTA; 2010 [cited 2020 April 1]. Available from: https://donatelife.gov.au/ resources/clinical-guidelines-and-protocols/national-protocol-donation-after-cardiac-death-2010
  6. The Transplantation Society of Australia and New Zealand (TSANZ). Clinical Guidelines for Organ Transplantation from Deceased Donors [Internet]. Adelaide: TSANZ; 2019 [cited 2020 April1]. Available from: www.tsanz.com.au/organallocationguidelines/ index.asp
  7. Australian Organ and Tissue Authority (AOTA). DonateLife Network – Roles and responsibilities.Version 3 [Internet]. Canberra: AOTA; 2016 [cited 2020 April 1]. Available from: www.donatelife.gov. au/sites/default/files/DLN%20Roles%20and%20 Responsibilities%20Guidelines.pdf
  8. Australasian Transplant Coordinators Association (ATCA). National standard operating procedures: Organ allocation, organ rotations, urgent listings [Internet]. Canberra: ATCA; 2013 [cited 2020 April 1]. Available from: www.atca.org.au/files/G.%20NSOP%20Organ%20 Allocation,%20Organ%20Rotations%20and%20 Urgent%20listings-%200012013.pdf
  9. Smith Z. Hiding behind a mask: A grounded theory study of perioperative nurses’ experiences of participating in multi-organ procurement surgery [Internet]. PhD thesis. Perth: Curtin University; 2012 [cited 2020 April 1]. Available from: https://espace. curtin.edu.au/handle/20.500.11937/1831
  10. Smith Z, Leslie G, Wynaden D. Australian perioperative nurses’ experiences of assisting in multi-organ procurement surgery: A grounded theory study. Int J Nurs Stud 2015;52(3):705–715. DOI: 10.1016/j.ijnurstu.2014.12.004
  11. Australian Organ and Tissue Donation and Transplantation Authority Act 2008.
  12. Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian charter of healthcare rights 2nd ed. [Internet]. Canberra: ACSQHC; 2019 [cited 2020 April 1]. Available from: www.safetyandquality. gov.au/publications-and-resources/resource-library/ australian-charter-healthcare-rights-second-edition-a4-accessible
  13. National Health and Medical Research Council (NHMRC). Organ and tissue donation after death, for transplantation. Guidelines for ethical practice for health professionals [Internet]. Canberra: Australian Government; 2016 [cited 2020 April 1]. Available from: www.nhmrc.gov.au/about-us/publications/ethical-guidelines-organ-transplantation-deceased-donors
  14. International Council of Nurses (ICN). The ICN Code of Ethics for Nurses [Internet]. Geneva:ICN, 2012. [cited 2020 April 1]. Available from: www.icn.ch/sites/default/ files/inline-files/2012_ICN_Codeofethicsfornurses_%20 eng.pdf
  15. Bell L. Using OR patient classification for staffing assignments. AORN J 2015;101(6):639–649. DOI: 10.1016/j.aorn.2015.03.003
  16. Butler V, Clinton C, Sagi HK, Kenney R, Barsoum WK. Applying science and strategy to operating room workforce management. Nurs Econ 2012;30(5):275–281.
  17. Nursing and Midwifery Board of Australia (NMBA). Decision-making framework for nursing and midwifery. [Internet]. Canberra: NMBA; 2020 [cited 2020 April 1]. Available from: www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Frameworks.aspx
  18. Australasian Transplant Coordinators Association – Transplantation Society of Australia and New Zealand
  19. (ATCA–TSANZ). National standard operating procedures: Packaging, labelling, storage and documentation of deceased donor vessels [Internet]. ATCA–TSANZ; 2016 [cited 2020 April 1]. Available from: www.tsanz.com.au/standalonepages/ documents/0032016_DeceasedDonorVessels.pdf
  20. ElBardissi AW, Wiegmann DA, Henrickson S, Wadhera R, Sundt TM 3rd. Identifying methods to improve heart surgery: An operative approach and strategy for implementation on an organizational level. Eur J Cardiothorac Surg 2008;34(5):1027–1033. DOI: 10.1016/j.ejcts.2008.07.007
  21. ElBardissi AW, Sundt TM 3rd. Human factors and operating room safety. Surg Clin North Am 2012;92(1):21–35. DOI: 10.1016/j.suc.2011.11.007
  22. Gallagher AG, Ritter EM, Champion H, Higgins G, Fried MP, Moses G et al. Virtual reality simulation for the operating room: Proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005;241(2):364–372. DOI: 10.1097/01.sla.0000151982.85062.80
  23. Baylis OJ, Adams WE, Allen D, Fraser SG. Do variations in the theatre team have an impact on the incidence of complications? BMC Ophthalmol 2006;6:13. DOI:10.1186/1471-2415-6-13. DOI: 10.1186/1471-2415-6-13
  24. Adams WE, Baylis OJ, Fraser SG. Does the scrub nurse matter? Eye 2007;21(1):116–118. DOI: 10.1038/sj.eye.6702421
  25. Talsma A, Anderson C, Geun H, Guo Y, Campbell DA. Evaluation of OR staffing and post-operative patient outcomes. AORN J 2013;97(2):230–242. DOI: 10.1016/j.aorn.2012.11.020
  26. Bathish M, McLaughlin M, Talsma A. Relationship between operating room nursing staff expertise and patient outcomes. J Nurs Care Qual 2015;30(2):167–174. DOI: 10.1097/NCQ.0000000000000092
  27. Koh RY, Park T, Wickens CD. An investigation of differing levels of experience and indices of task management in relation to scrub nurses’ performance in the operating room: Analysis of video-taped caesarean section surgeries. Int J Nurs Stud 2014;51(9):1230–1240. DOI: 10.1016/j.ijnurstu.2014.01.005
  28. Knowles M, Holton E, Swanson R. The adult learner: The definitive classic in adult education and human resource development. 7th ed. Oxford: Butterworth- Heinemann, Elsevier; 2011.
  29. Lyons P, Treasure E. The design and implementation of an organ donation education workshop for perioperative nurses. ACORN J 2014;27(1):28–32.
  30. Porra M. The Prince Charles Hospital retrieval team: Simulation nurse training programme for organ retrieval. Transplant Nurses Journal 2011;20(1):15–16.
  31. Wood C, Buss C, Buttery A, Gardiner D. Evaluation of deceased donation simulation. JICS 2012;13(2):107–114. https://doi.org/10.1177/175114371201300206
  32. Henderson K, Frengley R. Presenting new protocols using simulation: Organ donation after cardiac death. Paper presented at the SimTecT Health 2010: Education and Innovation in Healthcare Conference, Melbourne, Australia; 2010. Formerly available from: www.simulationaustralia.org.au/mysimaust/show_ abstract/1169.
  33. Xiao Y, Jones A, Zhang BB, Bennett M, Mears SC, Mabrey JD et al. Team consistency and occurrences of prolonged operative time, prolonged hospital stay, and hospital readmission: A retrospective analysis. Presentations from the 9th Annual Electric Utilities Environmental Conference 2015;39(4):890–896.
  34. Leach LS, Myrtle RC, Weaver FA, Dasu S. Assessing the performance of surgical teams. Health Care Manage Rev 2009;34(1):29–41. DOI: 10.1097/01.HMR.0000342977.84307.64
  35. Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanström LL. Surgical time independently affected by surgical team size. American J Surg 2009;198(2):216–222. DOI: 10.1016/j.amjsurg.2008.10.016
  36. Steinberger DM, Douglas SV, Kirschbaum MS. Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. Prog Transplant 2009;19(3):208–214. DOI: 10.7182/prtr.19.3.jhq1l24784v47181
  37. Xu R, Carty JM, Orgill DP, Lipsitz SR, Duclos A. The teaming curve: A longitudinal study of the influence of surgical team familiarity on operative time. Ann Surg 2013;258(6):953–957. DOI: 10.1097/SLA.0b013e3182864ffe
  38. Anderson C, Talsma A. Characterizing the structure of operating room staffing using social network analysis. Nurs Res 2011;60(6):378–385. DOI: 10.1097/NNR.0b013e3182337d97
  39. Wahr JA, Prager RL, Abernathy JH, Martinez EA, Salas E, Seifert PC et al. Patient safety in the cardiac operating room: Human factors and teamwork: A scientific statement from the American heart association. Circulation 2013;128(10):1139–1169. DOI: 10.1161/CIR.0b013e3182a38efa
  40. Nurok M, Sundt TM 3rd, Frankel A. Teamwork and communication in the operating room: Relationship to discrete outcomes and research challenges. Anesthesiol Clin 2011;29(1):1–11. DOI: 10.1016/j.anclin.2010.11.012
  41. Zheng B, Panton O, Al-Tayeb T. Operative length independently affected by surgical team size: Data from 2 Canadian hospitals. Can J Surg 2012;55(6):371–376. DOI: 10.1503/cjs.011311
  42. Poolton JM, Wilson MR, Malhotra N, Ngo K, Masters RSW. A comparison of evaluation, time pressure, and multitasking as stressors of psychomotor operative performance. Surgery 2011;149(6):776–782. DOI: 10.1016/j.surg.2010.12.005
  43. ElBardissi, AW, Duclos A, Rawn JD, Orgill DP, Carty MJ. Cumulative team experience matters more than individual surgeon experience in cardiac surgery. J Thorac Cardiovasc Surg 2013;145(2):328–333. DOI: 10.1016/j.jtcvs.2012.09.022
  44. Sykes M, Gillespie BM, Chaboyer W, Kang E. Surgical team mapping: Implications for staff allocation and coordination. AORN J 2015;101(2):238–248. DOI: 10.1016/j.aorn.2014.03.018
  45. Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. Deconstructing intraoperative communication failures. J Surg Res 2012;177(1):37–42. DOI: 10.1016/j.jss.2012.04.029
  46. Ausania F, White SA, Pocock P, Manas DM. Kidney damage during organ recovery in donation after circulatory death donors: Data from UK National Transplant Database. Am J Transplant 2012;12(4):932–936. DOI: 10.1111/j.1600-6143.2011.03882.x
  47. Xiao Y, Schenkel S, Faraj S, Mackenzie C, Moss J. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med 2007;50(4):387–395. DOI: 10.1016/j.annemergmed.2007.03.027
  48. Riley R, Forsyth R, Mania E, Iedema R. Whiteboards: Mediating professional tensions in clinical practice. Commun Med 2007;4(2):165–175. DOI: 10.1515/CAM.2007.020
  49. Schimpff S. Improving operating room and perioperative safety: Background and specific recommendations. Surg Innov 2007;14(2):127–135. DOI: 10.1177/1553350607301746
  50. Einav Y, Gopher D, Kara I, Ben-Yosef O, Lawn M, Laufer N et al. Preoperative briefing in the operating room: Shared cognition, teamwork, and patient safety. Chest 2010;137(2):443–449 DOI: 10.1378/chest.08-1732
  51. Phadnis J, Templeton-Ward O. Inadequate preoperative team briefings lead to more intraoperative adverse events. J Patient Saf 2015; Apr 22 DOI: 10.1097/PTS.0000000000000181
  52. Nagpal K, Vats A, Lamb B, Ashrafian H, Sevdalis N, Vincent C et al. Information transfer and communication in surgery: A systematic review. Ann Surg 2010;252(2):225–239. DOI: 10.1097/SLA.0b013e3181e495c2
  53. Salas E, Frush K. Improving patient safety through teamwork and team training. Oxford: Oxford University Press; 2012.
  54. Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: A narrative synthesis of the literature. BMJ Qual Saf 2014;23(5):359–372. DOI: 10.1136/bmjqs-2013-001848
  55. Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM 3rd. Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation. Surgery 2007;142(5):658–665. DOI: 10.1016/j.surg.2007.07.034
  56. Salas E, Stagl KC, Burke CS, Goodwin GF. Fostering team effectiveness in organizations: Toward an integrative theoretical framework. Nebr Symp Motiv 2007;52:185– 243.
  57. World Health Organization (WHO). WHO Guidelines for safe surgery. Safe surgery saves lives [Internet]. Geneva: WHO; 2009 [cited 2015 April 27]. Available from: http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf?ua=1
  58. Antoniadis S, Passauer-Baierl S, Baschnegger H, Weigl M. Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res 2014;188(1):21–29. DOI: 10.1016/j.jss.2013.12.002
  59. De Moraes EL, dos Santos MJ, Merighi MAB, Massarollo MCKB. Experience of nurses in the process of donation of organs and tissues for transplant. Rev Lat Am Enfermagem 2014;22(2):226–233. DOI: 10.1590/0104-1169.3276.2406
  60. Perrin K, Jones B, Winkelman C. The co-existence of life and death for the perioperative nurse. Death Stud 2013;37(9):789–802. DOI: 10.1080/07481187.2012.692460
  61. Carter-Gentry D, McCurren C. Organ procurement from the perspective of perioperative nurses. AORN J 2004;80(3):417–431. DOI: 10.1016/s0001-2092(06)60535-8
  62. Regehr C, Kjerulf M, Popova SR, Baker AJ. Trauma and tribulation: The experiences and attitudes of operating room nurses working with organ donors. J Clin Nurs 2004;13(4):430–437. DOI: 10.1111/j.1365-2702.2004.00905.x
  63. Wang YJ, Lin CY. The experience of perioperative nurses involved in organ procurement. J Nurs Res 2009;17(4):278–285. DOI: 10.1097/JNR.0b013e3181c0038d
  64. Joris J, Kaba A, Lauwick S, Lamy M, Brichant JF, Damas P et al. End of life care in the operating room for non-heart-beating donors: Organization at the University Hospital of Liege. Transplant Proc 2011;43(9):3441–3444. DOI: 10.1016/j.transproceed.2011.09.034
  65. Michael R, Jenkins HJ. Recovery from work-related trauma by perioperative nurses: The effects of social and personal resources. Collegian 2001;8(3):8–13. DOI: 10.1016/s1322-7696(08)60016-5
  66. Smith Z, Leslie G, Wynaden D. Perioperative nurses participating in multi-organ procurement surgery. ACORN J 2010;23(2):6–13.
  67. Odell J, Abhyankar R, Malcom A, Rua A. Conscientious objection in health professions: A reader’s guide to the ethical and social issues. Medsurg Nurs 2014;23(3):196– 198 [cited 2020 April 1]. Available from: scholarworks. iupui.edu/handle/1805/3844
  68. Work Health and Safety Act 2011 (Cth).
  69. Australian Nursing Federation (ANF). ANF policy conscientious objection [Internet]. Canberra: ANF; 2017 [cited 2020 April 1]. Available from: anmf.org.au/ documents/policies/P_Conscientious_Objection.pdf
  70. Lachman VD. Conscientious objection in nursing: Definition and criteria for acceptance. Medsurg Nurs 2014;23(3):196–198.