Does the Implementation of a Prone Positioning Checklists for Operation Theatre Nurses Improve Compliance with Prone Position Pressure Point Protection?

By WONG Wai Yan, Erica, RN, BSc (HONS), MS (HSM), Operating Theater


Even as technology continues to advance, one thing remains constant. Each and every patient must be correctly positioned for his or her procedure.

Prone positioning of a patient under anesthesia is a safe way of ensure optimum surgical access for a number of procedures.

Pressure injuries are a common but preventable issues, with implementation of best practice guideline and to comply with the 3 components of safe positioning of the surgical patient include knowledge, planning and teamwork is crucial.

Understanding of the changes in physiology and the particular risks associated with the prone position is vital since Improper positioning during surgery can lead to patient injuries.

A study in 2017 found that the use of a checklist when performing the prone maneuver increased the safety and reliability of the procedure.

Purpose and Problem Statement

Hong Kong Sanatorium Operating Theater (OT) recorded 3 pressure injury incidents in 2017 however, 5 incidents were reported within the first 2 quarters of 2018, and three out of five incidents were related to improper prone positioning.

Patient safety is our priority, with respect to our continuous improvement philosophy, the objectives of this project are:
•      To Standardize the process and improve safety of prone maneuver & positioning
•      To Improve compliance of perioperative team pressure points checking procedures
•      To Reduce pressure injury rate in prone positioning procedures

Implementation Plan

Checklist increases process safety by organizing the basic criteria to follow and condensing a large amount of knowledge into a brief format.

Implementation of a prone maneuver checklist is aim to facilitate a systematic & safe approach to patient care before, during and after patient has been prone positioned. A standard prone position diagram also provides to indicate 13 pressure points to check for after patient has been prone positioned in order to improve compliance of pressure points checking procedure.


Post data of total 18 cases collected during September 2018.

Result of the post data shown that there are 100% of perioperative team correctly used positioning devices and read instructions before prone maneuver.

Increased from pre data’s 28% there are 100% for the perioperative team did followed the diagram provided in the checklist to do the standard 13 pressure points checking and

pressure injuries rate reduced from 21% which is 4 out of 18 patients to 6% which is only one out of 18 patients developed redness on his upper chest wall after surgical procedure.

Recommendations and Next Steps

The safety and well-being of surgical patients are in the hands of the perioperative team when they enter the Operating theater.

After this Evidence base project, through the data and case study, aroused our perioperative team’s awareness to improve practice regarding prone positioning and result in improved patient safety.

It is essential to strive for continue improvement and provide better patient care with problem solving and critical thinking skills and evidence base practice to implement changes, collaborate and motivate our co-workers.

Also, periodically enforcing & renewal of patient maneuver protocols in all surgical positions help sustain our practice.

As stated at the beginning, with respect to our continuous improvement philosophy, we will regularly review perioperative team’s compliance for different surgical positions and update different positioning checklist to improve patient safety.

Also, we will develop checklist for other surgical positions and competency test in patient positioning to identify perioperative team’s knowledge and confidence level with pressure points checking procedure.

For long term improvement, we will discuss with perioperative team management and see if it is possible to add assigned person responsible for checking pressure points in operating theater electronic record system.

Also, we will collaborate with mentor group and provide checklist as a training material for new staffs. 

As we still recorded one patient with redness after prone surgical procedure, thus, we will introduce a dressing that statistically proved to prevent or reduce redness and skin breakdown to our patient.