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284
Abstract: Introduction and purpose: Falling of instru-
ments is seen as a major problem and defect in the most
surgical procedures. Instruments’ fall leads to increase in
operating time, surgical flow disruptions, more cost and
possible damage to surgical instruments. Due to the ef-
ficiency of magnetic drapes and the maintenance of in-
struments in the field of surgery, some of Instruments’
fall and its adverse effects on the operating room effi-
ciency are prevented. Thus, this study was undertaken to
investigate the effect of magnetic drapes on the falling of
instruments during neurosurgical, general, gynecological,
orthopedic and urological operations.
Materials and Methods: After making and testing the
magnetic drape, the clinical data were recorded by intra-
operative observation using a Self Administered checklist
in two groups of control and intervention during 200 neu-
rosurgical, general, gynecological, orthopedic and urolog-
ical procedures.
Results: The results of this study showed that the fre-
quency of instruments fall in the intervention group sig-
nificantly decreased (P <0.05).
Conclusion: Falling of instruments frequently occur in the
operating room and have a major effect on surgery flow
and resource utilization. Thorough documentation of in-
traoperative falling of instruments provides a basis for the
development of solutions for improving operating room
efficiency. According to the results of present study, it can
be concluded that magnetic drape had a significant effect
on reducing the falling of instruments during neurosur-
gical, general, gynecological, orthopedic and urological
procedures. So, designing and manufacturing magnetic
drape is recommended for the safety and comfort of sur-
gical team members and the removal of additional cost.
Keywords: Surgical instruments, operating room, fall,
magnetic, drape.
Investigating the effect of using magnetic
drape on preventing instruments fall during
surgery in Alzahra Medical educational
Center of Isfahan in 2017
Amin Sedigh1, Mohammad Ghasembandi2, Soheila Mojdeh3, Mehdi Rasti4, Sara Bagheri5*
1MSc student in Operating Room, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran;
https://orcid.org/0000-0001-5520-1211
2MSc student in Operating Room, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran;
https://orcid.org/0000-0003-1070-0855
3Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran;
https://orcid.org/0000-0001-6039-0176
4Associate Professor, plastic Surgery Specialist, Medical Sciences University, Isfahan University of Medical Science, Isfahan, Iran; https://orcid.org/0000-0002-7002-2470
5MSc student in Operating Room, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran;
https://orcid.org/0000-0001-8279-3400
*Corresponding Author: Sara Bagheri, MSc student in Operating Room, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical
Sciences, Isfahan, Iran. Corresponding Author Email: Bagherisep1993@gmail.com
Investigando el efecto del uso de la protección magnética en la prevención de caídas durante la cirugía en el
Centro educativo de Alzahra Medical en Isfahan en 2017
Resumen Abstract
Introducción y propósito: la caída de los instrumentos
es vista como un problema y defecto importante en la
mayoría de los procedimientos quirúrgicos. La caída de
los instrumentos aumenta el tiempo de operación, las
interrupciones del flujo quirúrgico, más costos y posibles
daños a los instrumentos quirúrgicos. Debido a la eficien-
cia de las cortinas magnéticas y al mantenimiento de los
instrumentos en el campo de la cirugía, se evitan algu-
nas caídas de los instrumentos y sus efectos adversos en
la eficiencia de la sala de operaciones. Por lo tanto, este
estudio se realizó para investigar el efecto de las corti-
nas magnéticas en la caída de los instrumentos durante
operaciones neuroquirúrgicas, generales, ginecológicas,
ortopédicas y urológicas.
Materiales y métodos: Después de realizar y probar la
capa magnética, los datos clínicos se registraron mediante
observación intraoperatoria utilizando una lista de verifi-
cación auto administrada en dos grupos de control e in-
tervención durante 200 procedimientos neuroquirúrgicos,
generales, ginecológicos, ortopédicos y urológicos.
Resultados: Los resultados de este estudio mostraron
que la frecuencia de los instrumentos en el grupo de in-
tervención disminuyó significativamente (P <0.05).
Conclusión: la caída de los instrumentos ocurre con fre-
cuencia en la sala de operaciones y tiene un efecto impor-
tante en el flujo de la cirugía y la utilización de recursos.
La documentación exhaustiva de la caída intraoperatoria
285
Revista Latinoamericana de Hipertensión. Vol. 14 - Nº 4, 2019
www.revhipertension.com
de instrumentos proporciona una base para el desarrollo
de soluciones para mejorar la eficiencia de la sala de opera-
ciones. De acuerdo con los resultados del presente estudio,
se puede concluir que la caída magnética tuvo un efecto
significativo en la reducción de la caída de los instrumen-
tos durante procedimientos neuroquirúrgicos, generales,
ginecológicos, ortopédicos y urológicos. Por lo tanto, se
recomienda el diseño y la fabricación de cortinas magnéti-
cas para la seguridad y la comodidad de los miembros del
equipo quirúrgico y la eliminación de costos adicionales.
Palabras clave: Aparatos quirúrgicos, quirófano, caída,
magnéticos, drapeados.
ithin each operating room (OR)
suite, there are many instru-
ments used by the surgical
team members. And then the falling of instrument seems
to be a common incident and also a deterrent to most of
the surgery. This issue is very important, which can have
short and long-term effects, leading to surgical flow dis-
ruption, the imposition of additional time and costs, and
the shortening the longevity of instruments. Surgical in-
strument fall as an interruption factor may affect nega-
tively the surgical team’s ability to remain fully engaged
mentally during a case. Also, the noise caused by the mov-
ing or falling of the surgical instrument leads to distrac-
tion of the surgical team. Surgical team members should
give their full attention to carrying out duties performed
during critical phases2. As mentioned by Wiegmann, sur-
gical flow disruptions related to resource accessibility ac-
counted for the remaining 8% of the observed events
during 31 nonemergency cardiovascular operation3. Joshi
and colleagues reported an average delay of 5.7 min after
the fall of the surgical instrument4. As a result of prolong-
ing the procedure, the patient is placed at a higher risk
of infection or other serious complications. In addition,
other surgeries may be subsequently delayed, and time
wasted on the part of the surgeon and other hospital
staff. Harders and colleagues found that the second most
commonly recorded reason for delay in the operating
room, after patient clinical condition, was the availabil-
ity of instruments6. During surgery, contaminated instru-
ments should be properly and completely removed from
blood or tissue in the sterile field. On the other hand, the
instrument dropped to the floor remains there until the
completion of the surgery. Blood and foreign matter that
are not removed or are allowed to dry and harden may
become trapped in jaw serrations, between scissor blades,
or in box locks, making final cleaning more difficult and
the sterilization or disinfection process ineffective. It can
cause instruments to become stiff and eventually break.
Surgical instruments are a major financial investment in
every surgical facility, and processes should be in place
to protect this investment. The life of a surgical instru-
ment is dependent upon the way it is used and the care
it receives. It is a responsibility for the surgical team and
the operating room staff. Instruments should be handled
carefully and gently to avoid possible damage caused by
their becoming tangled, dented, and misaligned. During
and after surgery they should be placed in an appropriate
place to prevent them from falling7. Surgeons, assistants
and scrub nurses work very closely together handling the
same instruments in a confined space during surgery8.
Consequently, one of the factors influencing the inci-
dence of instruments fall is communication in the operat-
ing room. In recent research, verbal and non-verbal ex-
changes in the operating room (OR) have been evaluated;
commands are delayed, incomplete, or not received at all,
and frequently left unresolved9. Firth-Cozens found that
31% of all communications in the operative procedures
represent failures, a third of which had a negative impact
on the patient10. Halverson and colleagues claimed that
36% of communication errors were related to instrument
utilization11. Generally, there are three phases related to
the use of the instruments. First, the request for a tool
has to be handled, then the tool is used, and finally it
is disposed of1,2. An error in any of these phases can be
considered as a disruption to the surgical flow. In other
words, the tool request was not properly interpreted or
holding the required tool was not conducted properly
e.g., it was mishandled or dropped on ground12. Because
the most fallen surgical instruments include Hemostats,
needle holders, Scissors and Forceps, also the majority
of surgical instruments are stainless steel and stainless
steel can be magnetically absorbent, therefore, the use
of magnetic instrument holder will improve the efficiency
and safety of the transfer of tools to the surgeon when
they are needed. Thus, this study was undertaken to in-
vestigate the effect of magnetic drapes on the falling of
instruments during neurosurgical, general, gynecological,
orthopedic and urological operations3,4.
his experimental paper is divided into two sec-
tion. Firstly, Intra-operative observation of oper-
ative procedures was performed by first author
over two week periods. Surgical cases were distributed
across all days of the week, times within the day, surgi-
cal specialty, and surgeon within each specialty. A similar
sampling scheme was used for observation in order to
make a main checklist and record data sheet for two con-
trol and intervention group during study. A combination
of recorded observations was used to introduce the basic
checklist and categorize falling events. The topics of the
self-administered checklist were classified into 6 catego-
Introduction
Materials and methods
286
ries: Demographic information of the surgical team, surgi-
cal position, type of instrument, stage of falling, condition
followed falling of instrument during surgery, number of
falls per surgical operation. In the second section, we de-
signed and examined the particular magnetic drape for
this investigation. All 20 operating rooms committed to
full- time surgery in academic hospitals of Alzahra, affiliat-
ed to Isfahan University of Medical Sciences were selected
by the convenience sampling method. After applying the
criteria of entry and approval of participation in the study,
200 operations such as general surgeries, neurosurgeries
and urology, orthopedic, obstetrics and gynaecologic sur-
geries were randomly assigned to two groups (control and
Intervention) of 100 cases were recorded. We excluded
emergency and after-hours cases. Entry criteria included
being the first surgical operation of day and performing
open surgery. The first author entered all falls into the da-
tabase immediately after each case in both groups and the
magnetic drape was successfully used during surgeries in
an intervention group. The checklist validity was confirmed
through a survey of 10 members of the faculty. The data
were analyzed by SPSS ver.16 using descriptive and analyti-
cal statistics (Chi-square, Pearson, Fisher’s exact test, and
Kolmogorov-Smirnov tests) at a significance of 0.05.
A 2-week-long pilot project was initiated to introduce
and test the new checklist. After revisions were made, the
process was introduced into the first surgical case of the
day. A total of 200 neurosurgical, general, gynecologi-
cal, orthopedic and urological cases were observed dur-
ing the study. The surgeries were divided into control and
intervention groups. There were 512 surgeons and 200
scrub technicians who participated in the project. Surgical
residents participated in all cases. There was no significant
difference between the two groups in terms of age, gen-
der, and work experience (P-value>0.05). The frequency
distribution of the demographic characteristics of the
population under investigation in two groups of control
and Intervention is shown in (Table 1) & (Table 2). There
were 55 falls (55%) during control and 19 (19%) during
intervention surgeries. The results of this study showed
that the frequency of instruments fall in the intervention
group significantly decreased (P<0.05) (Table 3).
Table 1. Determining and comparing frequency distribution
work experience, gender and age of surgeons and residents
in two groups
Variable Group Signicance
Control Intervention
work
experience
1st year
resident
28 33
0.77
11.2% 12.6%
2nd year
resident
44 43
17.5% 16.5%
3rd year
resident
78 78
31.1% 29.9%
4th year
resident
34 37
13.5% 14.2%
5th year
resident
1 5
0.4% 1.9%
fellowship 8 6
3.2% 2.3%
Professor 58 59
23.1% 22.6%
Total 251 261
0.62
100.0% 100.0%
age
20-30 78 77
31.1% 29.5%
31-40 126 126
50.2% 48.3%
Up to 40 47 58
18.7% 22.2%
Total 251 261
100.0% 100.0%
gender
male 186 194
0.95
74.1% 74.3%
Female 65 67
25.9% 25.7%
Total 251 261
100.0% 100.0%
Table 2. Determining and comparing frequency distribution
work experience, gender and age of scrub nurses in two
groups
Variable Group Total Signicance
Control Intervention
work
experience
Lowest
1 Year
5 1 6
0.20
83.3% 16.7% 100.0%
1-2
Years
12 16 28
42.9% 57.1% 100.0%
Up to 2
years
83 83 166
50.0% 50.0% 100.0%
Total 100 100 200
50.0% 50.0% 100.0%
age
20-30 44 43 87
0.80
50.6% 49.4% 100.0%
31-40 30 34 64
46.9% 53.1% 100.0%
Up to 40 26 23 49
53.1% 46.9% 100.0%
Total 100 100 200
50.0% 50.0% 100.0%
gender
male 23 26 49
0.62
46.9% 53.1% 100.0%
Female 77 74 151
51.0% 49.0% 100.0%
Total 100 100 200
50.0% 50.0% 100.0%
Results
287
Revista Latinoamericana de Hipertensión. Vol. 14 - Nº 4, 2019
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Table 3. Determining and comparing frequency of instru-
ments fall in two groups
Variable Instruments Fall Total Signicance
No Yes
Group
Control 45 55 100
0.002*
45.0% 55.0% 100.0%
Intervention 81 19 100
81.0% 19.0% 100.0%
Total 126 74 200
63.0% 37.0% 100.0%
In control group 40 falls (52.6%) in supine position, 6 falls
(66.7%) in lateral position, 2 falls (28.6%) in prone posi-
tion and 7 falls (87.5%) in lithotomy position occurred,
while in intervention group 14 falls (19.4%) in supine po-
sition, 2 falls (20%) in prone position and 3 falls (21.4%)
in lithotomy position were noted.The results also showed
that there was a significant difference between frequency
of instruments fall in supine(P-value=0.001 <0.05) and
lithotomy(P-value=0.006 <0.05) position. The type of the
falling surgical instruments was also noted. Out of a total
of 55 instruments falling on the floor in control group,
there were 53 falls involving instruments set like forceps,
scissors, clamp, needle holders and 2 implants. And all
of instruments falling on the floor in intervention group
were involved instruments set. There were no significant
difference in the types of instruments falling observed (P-
value>0.05). During the observation period, the causes
of instruments’ fall in control (49.1%) and intervention
(57.9%) group was related most commonly to time that
the tools were left on the side of the patient body, at a
reachable region, but outside the opening incision, and
reused later by surgeon (Table 4). Ignoring instruments
dropped on the floor was the most common condition
after falling surgical instruments in both groups (Table
5). Seven surgeries had two or more falls. The results are
based on Chi-square and Fisher’s exact test non-paramet-
ric tests at a significance of 5% (due to the fact that the
distribution of satisfactory score is not normal based on
Kolmogorov-Smirnov results (P-value=0.001 <0.05)).
Table 4. Determining and comparing frequency of stage of instruments fall in two groups
Variable Group Total Signicance
Group Intervention
Fall stage
Picking up tool from mayo stand or instrument table 3 3 6
0.43
5.5% 15.8% 8.1%
Arranging tools by scrub nurse 8 2 10
14.5% 10.5% 13.5%
Requesting and transferring tool between sterile team members 3 0 3
5.5% 0.0% 4.1%
Handling and utilization of tool in the sterile eld 14 3 17
25.5% 15.8% 23.0%
Disposing and placing tool on the patient body, outside the opening incision 27 11 38
49.1% 57.9% 51.4%
Total 55 19 74
100.0% 100.0% 100.0%
Table 5. Determining and comparing frequency of condition followed falling of instruments during surgery in two groups
Variable group Total Signicance
Control Intervention
Fall condition
To request alternative tool as single
instrument
4 0 4
0.61
7.3% 0.0% 5.4%
To request alternative tool as instrument set 5 1 6
9.1% 5.3% 8.1%
To request resterilization of contaminated
tool
1 0 1
1.8% 0.0% 1.4%
Ignoring tool dropped on the oor and to
replace it with present instruments
45 18 62
80.0% 94.7% 83.8%
Total 55 19 74
100.0% 100.0% 100.0%
288
o our knowledge, no scientific data evaluating
the effect of instrument holders and magnetic
drapes on preventing instruments fall during
surgeries. The studies evaluating the incidence of acci-
dental fall of instruments during elective and emergency
caesarean section and orthopaedic procedures have led
to analyse and compare statistically the occurrence instru-
ment fall, which can be applied in a modified manner to
studies similar to ours.
In the study by Joshi et al4., which was conducted at V. C.
S. G. G. Medical Sciences and Research Institute) Srinagar,
Pauri Garhwal, India, 362 randomly chosen emergency
and elective caesarean sections was observed. The results
showed that gynaecological instruments fall in one-sixth
of elective caesarean sections and in approximately ev-
ery second emergency caesarean sections. The operating
surgeon and his/her first assistant were responsible for
83.64% of instrument falls in the operating room. This
is practicaly the same as the study performed on acci-
dentally falling instruments during orthopedic surgery in
2008 by khan et al. Their analysis reveals that orthopedic
instruments fall in one third of elective procedures and in
approximately every second trauma orthopedic one. Also,
more than 80% of instrument/implant falls in the operat-
ing room occurred as a result of the operating surgeon
and his/her first assistant13. In both previous studies, the
nature of instrument falling during surgery indicates that
falls are more common with smaller instruments (like for-
ceps) and with instruments having a steel handle.
Our study concluded that to prevent instruments from
falling from the surgical field, the scrub person may place
a magnetic pad on the drapes below the incision site
when the patient is placed in especially supine and lithot-
omy position. However, the scrub nurse has also created
a small area on drape with the magnetic drape dedicated
for the 4-5 most frequently and currently used tools (Fig-
ure 1). These instruments are placed in a particular order.
In this example the scrub nurse places the instrument an-
ticipated to be used next, nearest to the surgeon.
After use, the items are placed back in the magnetic
zone, and the scrub person retrieves them. This technique
eliminates hand-to-hand passing of sharps between the
surgeon and the scrub person, so that no two individu-
als touch the same sharp at the same time and prevents
instruments lying on the surgical field from sliding to the
floor. Rahmati and colleagues confirmed that the use
of needle magnet within surgical field may reduce the
chances of sharps injury during surgery14. The evidence
from our study suggests that it’s better to remove instru-
ments from the surgical field after use, and return them
to the Mayo stand or instrument table promptly. But ac-
cording to Svensson and colleagues’ findings, the use and
handling of instruments is embedded in a complex weave
of multiple interrelated activities and responsibilities. For
example, the passing is done in relation to other distinct
and parallel activities15. Because the scrub nurse does not
just respond to a request by quickly removing and pass-
ing the correct instrument, he/she can define a location
on the surgical field where instruments are placed on a
magnetic drape, from which the surgeon or assistant can
retrieve them. The findings of our study illustrate condi-
tions underlying the causes of falling instruments during
surgeries in general. Finally, we suggest that further inves-
tigations are needed to estimate the association between
falling of instruments and perioperative delay, additional
subsequent delays, errors, system deficiencies, longevity
of instruments and cost-effectiveness6,7. We aware that
our research may have limitations. First, all surgical team
members, type of surgeries, duration of surgeries are dif-
ferent between two groups. Another important limitation
is the way in which falling of instruments were recorded.
There is no established classification in the literature8,9,10;
thus, we developed our own checklist. We hope that the
data from this study can be used to show that falling of in-
struments does happen frequently and to elevate aware-
ness about them so that appropriate surgical instrument
holders like magnetic drapes can be used to prevent them.
urgical operations where nurses and sur-
geons routinely pass instruments to one an-
other. The key to the successful accomplish-
ment of a surgical intervention is the timely availability
and efficiency of tools. Surgical instruments not working
properly or not immediately available may delay proce-
dures, interrupt other activities or sometimes even endan-
ger the safety of the patient. The handling and exchange
of instruments during the surgical operation raises issues
that may bear upon the development of technologies. A
magnetic drape is one of new surgical technology that it
is necessary to position a magnetic instrument pad over
the top drape to serve as a neutral zone, and also to retain
Discussion
Figure 1. Use of the magnetic drape during surgery with
lithotomy position
Conclusions
289
Revista Latinoamericana de Hipertensión. Vol. 14 - Nº 4, 2019
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any instruments that are placed on the drape. In conclu-
sion, the use of the magnetic drape will make the surgical
procedures more proficient, decrease loss and improve the
transfer of instruments to the surgeon by keeping them in
a safe but reachable distance maximizing the organization
of the surgery.
Acknowledgement: The present paper is drawn from
one of the parts of the master’s thesis of the operating
room approved by the code 396872 at Isfahan University
of Medical Sciences. Hereby, I express gratitude to the en-
tire staff working in operating room and the officials of
Isfahan’s Alzahra Hospital. Also, I greatly thank the Isfahan
University of Medical Sciences and the research office for
cooperating and their funding the project.
1. Hensler RS, inventor; USPTO, assignee. Surgical table magnetic instru-
ment holder. US patent 9,060,913. 2015.
2. Association of Perioperative Registered Nurses. AORN position state-
ment on managing distractions and noise during perioperative patient
care. AORN journal 2014; 99(1):22-26.
3. Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM. Dis-
ruptions in surgical flow and their relationship to surgical errors: an
exploratory investigation. Surgery 2007; 142(5):658-665.
4. Joshi C, Joshi AK, Pal B, Mohsin Z, Sharma R. Incidence of Instrument
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dical Science 2012; 11(2):87-90.
5. Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating
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516.
6. Spry CC. Care and handling of basic surgical instruments. AORN jour-
nal2007; 86(S1): S77-S81.
7. Berguer R, Heller PJ. Preventing sharps injuries in the operating room.
Journal of the American College of Surgeons 2004; 199(3):462-467.
8. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al.
Communication failures in the operating room: an observational clas-
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13(5):330-334.
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References
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