Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks

BMJ Qual Saf. 2012 Sep;21(9):746-52. doi: 10.1136/bmjqs-2011-000138. Epub 2011 Aug 18.


Objective: To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned.

Methods: The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics.

Results: Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR.

Conclusions: OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.

Publication types

  • Comparative Study

MeSH terms

  • Air Movements*
  • Awareness
  • Environment, Controlled
  • Floors and Floorcoverings
  • Humans
  • Infection Control / methods
  • Infection Control / standards*
  • Operating Rooms / organization & administration
  • Operating Rooms / standards*
  • Ophthalmologic Surgical Procedures / instrumentation
  • Ophthalmologic Surgical Procedures / standards
  • Postoperative Complications / prevention & control
  • Safety Management
  • Surgical Instruments
  • Time and Motion Studies*