https://orcid.org/0000-0002-2792-1876
Figures
Abstract
Background
Occupational health hazards are ubiquitously found in the operating room, guaranteeing an inevitable risk of exposure to the surgeon. Although provisions on occupational health and safety in healthcare exist, they do not address non-traditional hazards found in the operating room. In order to determine whether surgeons or trainees receive any form of occupational health training, we examine the associations between occupational health training and exposure rate.
Study design
A cross-sectional survey was distributed. Respondent characteristics included academic level, race/ethnicity, and gender. The survey evaluated seven surgical disciplines and 13 occupational hazards. Multivariable logistic regression was used to examine the association between academic level, surgical specialty, and exposure rate.
Results
Our cohort of 183 respondents (33.1% response rate) consisted of attendings (n = 72, 39.3%) and trainees (n = 111, 60.7%). Surgical trainees were less likely to have been trained in cytotoxic drugs (OR 0.22, p<0.001), methylmethacrylate (OR 0.15, p<0.001), patient lifting (OR 0.43, p = 0.009), radiation (OR 0.40, p = 0.007), and surgical smoke (OR 0.41, p = 0.041) than attending surgeons. Additionally, trainees were more likely to experience frequent exposure to bloodborne pathogens (OR 5.26, p<0.001), methylmethacrylate (OR 2.86, p<0.001), cytotoxic drugs (OR 3.03, p<0.001), and formaldehyde (2.08, p = 0.011), to name a few.
Conclusion
Although surgeon safety is not a domain in residency training, standardized efforts to educate and change the culture of safety in residency programs is warranted. Our study demonstrates a disparity between trainees and attendings with a recommendation to provide formal training to trainees independent of their anticipated risk of exposure.
Citation: Landford WN, Ngaage LM, Lee E, Rasko Y, Yang R, Slezak S, et al. (2021) Occupational exposures in the operating room: Are surgeons well-equipped? PLoS ONE 16(7): e0253785. https://doi.org/10.1371/journal.pone.0253785
Editor: Leonidas G. Koniaris, Indiana University, UNITED STATES
Received: March 11, 2021; Accepted: June 14, 2021; Published: July 2, 2021
Copyright: © 2021 Landford et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its S1 File and S1–S4 Tables.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Surgeons are frequently exposed to a host of occupational hazards that all pose an established risk to their health and safety. In the operating room (OR), the ubiquity of these hazards guarantees inevitable exposure to blood-borne pathogens for approximately 5.6 million healthcare workers, an average of 5-50mrem/case, 10-350mrem/month, or 2000-3000mrem/year of radiation depending on the surgical specialty, and biological by-products from surgical smoke [1–4]. Accordingly, the collaborative nature of the surgical field places surgeons at risk of exposure to hazards not always specific to their own specialty. Vascular surgeons, Orthopedic surgeons, and Plastic surgeons working together on a complex operation may use intraoperative technologies that emit radiation or produce vibratory sound above recommended levels that may not be typical within their own respective specialties [3, 5]. While efforts have been made to improve OR safety through mandated occupational safety trainings, no policies or trainings exist on non-traditional hazards that address the chemical or biological materials emitted from laser or surgical smoke, anesthetic gases, or ergonomics, to name a few [1, 2].
Institutional practices and personal behaviors play a significant role in the implementation of occupational health and safety provisions. Current literature implies that underreporting of workplace injuries is prevalent and multifactorial in the surgical field [6–8]. A unique challenge to instilling policies is the lack of established exposure limits for several of the hazards as expert agency guidelines are either lacking or outdated. Several studies have demonstrated an increased incidence of malignancy, infertility, and shortened lifespan following prolonged and repeated exposure to common hazards in the OR [9–14]. However, these conclusions are based on a small number of studies and low-level evidence. Moreover, the literature is near void on the consequences of prolonged exposure over a surgeon’s career. Consequently, physicians may remain ignorant on the potential risks. Therefore, early awareness and education is imperative in reducing the economic, personal, and social implications of these non-traditional hazards.
The purpose of this study was to elucidate the extent to which surgeons are trained in OR hazards and assess the self-reported exposure rate across surgical specialties and academic level.
Methods
Study population & recruitment
The Institutional Review Board (IRB) at the Johns Hopkins University School of Medicine approved this study and deemed it exempt. A cross-sectional electronic questionnaire, Qualtrics (Qualtrics, version 1-0-0, Provo, CT) online survey and research tool, was distributed to surgical attendings (n = 72 (39.3%)), fellows (n = 11 (6%)), and residents (n = 100 (54.6%)) from June through August 2019 at Johns Hopkins Hospital and affiliated hospitals. No compensation was offered for completion of the survey. Recruitment for individual respondents was through email using the surgery department lists. Participants were invited to complete an online questionnaire through which informed consent was obtained. Incomplete surveys were avoided through completion control implemented in the online tool. Non-respondents were automatically reminded to complete the survey after 4 weeks through the Qualtrics platform. A total of three reminders were sent to nonrespondents. The non-respondent population was characterized by comparing demographic information of the entire emailed cohort to that of respondents.
Measures
Occupational hazards were selected following three round table discussions with a multidisciplinary group of surgeons at all academic levels. The survey instrument was revised from 28-items to 21-items based on the review, rewritten for clarity, and electronic survey logic was added. The revised questionnaire was pilot tested by a group of residents and attendings that represented the cohort of interested consisting of surgeons and trainees from the same institution. The multidisciplinary team was not included in the final survey study. Feedback was incorporated before the survey tool was finalized. This study followed the American Association for Public Opinion Research (AAPOR) disclosure checklist. All questions were multiple choice and included demographic information, current academic level, and surgical specialty. Fellows and residents were categorized as trainees. Surgical disciplines included General, Otolaryngology, Neurosurgery, Orthopedics, Plastic & Reconstructive surgery, Urology, and OBGYN. General surgery included Cardiac, Pediatric, and Vascular surgery.
The survey assessed four key areas: (i) whether the participants had ever received formal occupational hazard training, (ii) frequency of training, (iii) adequacy of training, and (iv) the frequency of exposure to occupational hazards within the last year. The frequency of training was reported as never received, received once during career, received yearly, or received monthly. Adequacy of training was evaluated on a five-point Likert scale where 1 = unacceptable and 5 = excellent.
The survey evaluated 13 occupational hazards: bloodborne pathogens, surgical smoke, ergonomics, radiation, sharp injuries, inhalation exposure to methylmethacrylate, cytotoxic drugs, formaldehyde, patient lifting, prolonged standing (more than 3 hours), surgical hand scrub, surgical noise (anesthesia machines, monitors, vibratory devices, suctioning, music), and anesthetic gases. Bloodborne pathogens were described as blood products, patient fluid products released during tissue debridement, and intraoperative blood products. Surgical smoke pertained to surgical plume released from cautery, cautery-like devices, or laser surgeries. Radiation sources included fluoroscopic intraoperative imaging (i.e. C-arm, mini C-arm) and plain radiographs. Ergonomics referred to intraoperative equipment use and use of loupes. Sharp injuries pertained to both needlestick and sharp injuries. Cytotoxic drugs included HIPEC, PIPAC, and mitomycin.
Statistical analysis
Data was compiled in Qualtrics and then converted to a Microsoft Excel spreadsheet (Microsoft 2016, Redmond, Washington) and analyzed using the Statistical Package for the Social Sciences (SPSS, Version 26 IBM Corp, 2019. IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp.). Descriptive analyses were performed to examine the individual effects of demographic, academic level, and surgical specialty. Surveys a with <90% item response rate and subgroups with fewer than 5 respondents were excluded from analysis. A total of 3 surveys were excluded following this exclusion criteria. Due to the low number of respondents who received training in any occupational hazard on a monthly basis (n = 2), monthly training was merged with the group that received annual training and called “annual or more frequent”. Exposure frequency was converted to a numeric ordinal scale for the purpose of analysis; 0 –never exposed, 1 –exposed once, 2 –yearly, 3 –monthly, 4 –weekly, 5 –few times per week, and 6 –daily. We reported the median and interquartile range for ordinal data. The Mann Whitney-U and Kruskal Wallis test were used to assess for significant differences in satisfaction, as appropriate. We calculated odds ratios (OR) and 95% confidence intervals (CI) to evaluate associations between training received on occupational hazards and the variable of interest (academic level and surgical specialty). Ordinal regression analysis was used to assess associations between exposure frequency and the variable of interest (academic level, surgical specialty, and receipt of occupational hazard training). Statistical significance was defined as a two-tailed value of p≤0.05.
Results
A total 183 of 553 respondents (33.1% response rate) participated in the survey. Differences between the respondent and non-respondent populations are summarized in S1 Table. Among respondents, over half included surgical trainees (n = 111, 60.7%) and the rest were attendings. Respondents were categorized into seven surgical specialties, with a majority from General Surgery (30.6%). Ethnic representation demonstrated a predominantly Caucasian cohort. A complete summary of all demographic and training level characteristics can be found in S1 Table.
Occupational hazard training
Respondents were asked to indicate whether they had received any form of training or educational material on 13 occupational OR hazards. Nearly all respondents reported receiving some form of training or material on bloodborne pathogens (96.2%) and needlestick/sharp injuries (96.2%). Two-thirds of respondents were trained in radiation (64.5%) and methylmethacrylate (64.5%) but very few respondents received formal training on surgical noise (12.6%) or prolonged standing (7.1%) (S2 Table). When respondents were stratified by academic level and surgical specialty, significant differences were noted in the receipt of chemical and physical occupational hazard training (Tables 1–3).
Chemical hazards.
Surgical trainees were less likely to have been trained in cytotoxic drugs (OR 0.22, p<0.001) and methylmethacrylate (OR 0.15, p<0.001) than attending surgeons. Across surgical specialties, Neurosurgeons (OR 66.00, p<0.001) and Orthopedic surgeons (OR 42.78, p<0.001) were also found to have greater odds of receiving training in methylmethacrylate. Neurosurgeons were more likely to be trained in formaldehyde (OR 5.52, p = 0.009) (Table 2).
Physical hazards.
Surgical trainees had lower odds of receiving training in patient lifting (OR 0.43, p = 0.009), radiation (OR 0.40, p = 0.007), and surgical smoke (OR 0.41, p = 0.041) than attending surgeons. Otolaryngologists (OR 3.12, p = 0.041) and Neurosurgeons (OR 3.97, p = 0.035) were also found to have greater odds of receiving training in surgical smoke. Neurosurgeons were more likely to be trained in surgical noise (OR 3.97, p = 0.035) (Table 3).
Frequency of occupational hazard training
We then analyzed the influence of academic level and surgical specialty on frequency of training (Tables 1–3). Bloodborne pathogens and needlestick or sharp injuries were the most frequently trained; more than half of the trained respondents received training at yearly intervals (57%, and 55%, respectively). Frequency of occupational hazard training was similar across academic levels. However, Orthopedic surgeons were less likely to receive training in anesthetic gases more than once (OR 0.17, p = 0.047) (Table 2).
Satisfaction with occupational hazard training
Overall, respondents who received education believed that they had satisfactory training on a majority of occupational hazards (S3 Table). Training on bloodborne pathogens and needlestick or sharps injury training was found to be “very good” (median rating 4, IQR: 3–5). On further analysis, satisfaction with training differed significantly for two chemical hazards. Trainees had a higher median satisfaction score for formaldehyde training than attendings (4 vs 3, p = 0.037). Across surgical specialties, no statistical difference in satisfaction was noted for any occupational hazard training.
Occupational hazard exposure
Respondents also reported their frequency of exposure to each occupational hazard within the last year (S4 Table). Bloodborne pathogens, surgical smoke, patient lifting, surgical noise, prolonged standing, and surgical scrub were reported to have the highest frequency of exposure (Daily). Respondents reported rarely experiencing exposure to methylmethacrylate, needlestick/sharp injuries, cytotoxic drugs, and formaldehyde (Yearly). Subgroup analysis showed different patterns of hazard exposure for attendings and trainees. Furthermore, the odds of exposure to occupational hazards was not equal across surgical specialties (Table 4).
Biological hazards.
Trainees had greater odds of experiencing frequent exposure to bloodborne pathogens compared to attending surgeons (OR 5.26, p<0.001). Otolaryngologists reported low odds of exposure to needlestick/sharp injuries (OR 0.32, p = 0.036).
Chemical hazards.
Trainees reported increased odds of exposure to methylmethacrylate (OR 2.86, p<0.001), cytotoxic drugs (OR 3.03, p<0.001), and formaldehyde (2.08, p = 0.011) than attending surgeons. Orthopedic surgeons reported lower odds of exposure to cytotoxic drugs (OR 0.13, p = 0.001). The odds of methylmethacrylate exposure was significantly greater among Plastic surgery (OR 1.80, p<0.001), Neurosurgery (OR 8.64, p<0.001), and Orthopedic surgery (OR 29.02, p<0.001).
Physical hazards.
Compared to attendings, residents and fellows were more likely to be exposed to patient lifting (OR 19.79, p<0.001), radiation (OR 5.14, p<0.001), prolonged standing (OR 11.78, p<0.001), surgical noise (OR 10.87, p<0.001), and surgical smoke (OR 18.54, p<0.001) when compared to surgical trainees. Neurosurgery (OR 4.59, p = 0.012), orthopedic surgery (OR 6.93, p<0.001), and urology (OR 5.56, p = 0.007) had increased odds of radiation exposure while OBGYN had lower odds of encountering radiation (OR 0.18, p = 0.001). Conversely, exposure to surgical smoke (OR 0.16, p = 0.001) and prolonged standing (OR 0.23, p = 0.007) was less likely among OBGYN physicians.
We then assessed the relationship between receipt of training and exposure frequency for each occupational hazard. Surgeons who received training on methylmethacrylate had greater odds of exposure (OR 3.03, p = 0.028) compared to surgeons who did not receive training. No significant association between receipt training and exposure frequency was noted for any other occupational hazard.
Multivariable analysis
We adjusted for academic level, surgical specialty, and receipt of hazard training in a multivariate ordinal regression analysis. We found that residents and fellows still experienced greater odds of exposure to bloodborne pathogens (OR 5.42, p<0.001), cytotoxic drugs (OR 3.60, p<0.001), formaldehyde (OR 2.19, p = 0.007), methylmethacrylate (OR 3.71, p<0.001), surgical scrub (OR 8.76, p<0.001), prolonged standing (OR 12.18, p<0.001), patient lifting (OR 20.49, p<0.001), radiation (OR 5.21, p<0.001), surgical noise (OR 11.02, p<0.001), and surgical smoke (OR 19.69, p<0.001) compared to attendings. Whereas odds of exposure to needlestick or sharps injury remained similar between surgical trainees and attending surgeons (OR 0.64, p = 0.120).
Discussion
Occupational safety and efficient workflow depend largely on the OR infrastructure, comfort level of the operative environment, recognition and awareness of potential hazards that are inescapable and part of the profession. Our study demonstrates a defining difference between specialties and an influence of training level on exposure and education. Training is not universal for any of the occupational hazards assessed. Despite a higher exposure frequency to various occupational hazards, surgical trainees were less likely to receive formal hazard training than attendings. Furthermore, surgical trainees had a greater exposure frequency to occupational hazards. Our results suggest that occupational hazard training may be selectively allocated to certain surgical specialties based on predicted frequency of hazard exposure.
Training and frequency
The Occupational Safety and Health Administration (OSHA) has created resources that provide information and training on hospital-wide hazards however healthcare worker training is limited to traditional hazards such as bloodborne pathogens and needlestick/sharp injuries [1, 2]. While surgeons are mandated to complete an OSHA biological hazards training, no such requirement exists for nontraditional hazards found in the OR. A worrisome finding among our respondents was the lack of global training on occupational hazards; no hazard had a 100% training rate. Furthermore, traditional occupational hazards (bloodborne pathogens and needlestick/sharp injuries) demonstrated the highest frequency of training at an annual rate whereas nontraditional hazard training often demonstrated a rate of only once in a surgeon’s career. Receiving training once per career may not result in retention of knowledge. Studies demonstrate that regular repetition of training is needed to retain high quality knowledge in medicine [15, 16]. This discrepancy may be due to the widespread acceptance of biological hazards as a hospital-wide harm [17–20]. In addition, a lack of or a more lenient implementation of institutional policy may exist for the nontraditional hazards that have little to no clinical data to support their impact on surgeon health. Nonetheless, previous studies have shown that nontraditional occupational hazards can be detrimental [4–6, 21–24]. Interestingly, attending surgeons and surgical trainees were disproportionately trained in occupational hazards. A reason for this difference may be that attending surgeons possess a greater opportunity for experience through their involvement at conferences/panels, CME courses, hospital affiliations, and department specific education. Across surgical specialties, hazards training demonstrated a specialty specific pattern. Surgical specialties such as Neurosurgery and Orthopedic surgery were found to be trained significantly more in hazards such as methylmethacrylate or surgical smoke. Radiation and cytotoxic drugs showed no significant pattern. Although specialty-specific, this may mean that no specialty is receiving more or less training. Overall, the complacency of the training received is an indication that surgeons may not understand the implications of exposure to nontraditional hazards.
Exposure
Respondents reported an expected daily exposure to a majority of the occupational hazards. The higher frequency of exposure among surgical trainees is noteworthy. Surgical trainees had a greater frequency of exposure than attending surgeons, which is attributed to the nature of residency. Residents spend, on average, 80 hours per week in the hospital. In that time, they manage a caseload of several senior surgeons and operate daily/nightly. On the other hand, attendings were less frequently exposed owing to the fact that they have dedicated operative and clinic days, and thus spend less time in the OR.
Surgical specialty-dependent exposure patterns were observed among several sub-specialties. Neurosurgery, Orthopedic surgery, and Urology shared a higher exposure frequency to radiation while Plastic surgery, Neurosurgery, and Orthopedic surgery were found to have a greater exposure to methylmethacrylate. Alternatively, exposure to radiation, surgical smoke, and prolonged standing was less likely among OBGYN. These exposure patterns may be viewed as predictable given the nature of operations performed by certain specialties. Neurosurgeons, Urologists, and Orthopedic surgeons have higher user rates of intraoperative imaging; methylmethacrylate has extensive use in arthroplasties and cranioplasties [25]. Interestingly, no statistical significance in exposure was found across specialties that perform a wide range of procedures (such as General surgery) or serve as consultants. Thus, the exposure experienced during consults appears to be incidental and underestimated.
Exposure and training
Fundamental to this survey was the assessment of training on hazard exposure. Although not uniformly distributed, our data suggests that surgical trainees reported frequent exposure to bloodborne pathogens, radiation, methylmethacrylate, prolonged standing, patient lifting, surgical smoke, cytotoxic drugs, formaldehyde, and surgical noise than attending surgeons that was irrespective of formal training, demonstrating increased vulnerability in the setting of a knowledge gap. Several factors that may contribute to this knowledge gap include poor personal protective equipment (PPE) compliance, inconsistent reporting protocols, and unfamiliarity with OSHA safety guidelines. Despite this, a lack of training to those more vulnerable to occupational hazards may have disastrous consequences (e.g. infertility in residents who are in prime fertile years, sickness resulting in medical leave from training and delays until graduation). Previous studies have shown the impact that resident education has on decreasing hazard exposure [26]. Resident education at one institution demonstrated a significant decrease in mini-C arm time when performing fracture reduction compared with radiation exposure prior to receiving the education [26, 27]. Given the grave consequences of ongoing exposure to many of these hazards, it is imperative that more stringent and regular training is implemented.
Limitations
Our study has several limitations. First, is the difference between our respondent and non-respondent populations. Our results suggest that trainees and certain surgical specialties were more likely to self-select and complete the survey. This introduces a bias and caution must be taken when extrapolating these results to a greater population. Secondly, the survey is based on self-report. All self-reported surveys are limited by the honesty of the respondents and accurate interpretation of survey questions. Efforts were made to ensure confidentiality of the responses to minimize this potential bias. In addition, recall bias with survey and acquiescence bias with Likert scales may overestimate or underestimate satisfaction. Thirdly, a survey response rate of 33.1% may limit generalizability of the results; however, this rate is comparable to the response rates found in other surveys involving surgeons [28–30]. The small sample size, particularly in subgroup analysis, may influence the results. On one hand, surgeons truly concerned about occupational exposures may have been more likely to respond than surgeons uninterested in hazards. Thirdly, responses from a multi-institutional hospital system that shares one department per specialty may have an impact on the external validity of the results. Lastly, receipt of formal training is only one method to receive information on occupational hazards. It is possible that surgeons learn about occupational hazards in a less structured format, such as word of mouth or idle talk in the OR. Future studies investigating surgeon knowledge of hazards are warranted.
Conclusion
We highlight gaps between training, perceived importance, and actual practice of occupational risk management among surgeons. In addition to this, supportive data that demonstrates the link between hazard and illness in this population is limited. We encourage medical institutions and surgical specialties to educate the next generation of surgeons on occupational hazards and ensure their protection during training–for the sake of surgeon safety.
Supporting information
S1 Table. Demographic characteristics of survey respondents and non-respondents.
https://doi.org/10.1371/journal.pone.0253785.s001
(DOCX)
S2 Table. Occupational hazards ranked from most trained to least trained.
https://doi.org/10.1371/journal.pone.0253785.s002
(DOCX)
S3 Table. Median rating of training received on occupational hazards based on a 5-point Likert scale (1 –inadequate, 5 excellent).
https://doi.org/10.1371/journal.pone.0253785.s003
(DOCX)
S4 Table. Median frequency of exposure to occupational hazards.
https://doi.org/10.1371/journal.pone.0253785.s004
(DOCX)
S1 File. Occupational hazards Qualtrics survey.
https://doi.org/10.1371/journal.pone.0253785.s005
(PDF)
References
- 1.
National Institute for Occupational Safety and Health (NIOSH). Workplace Safety & Health Topics. Center for Disease Control. 2016. Available from: https://www.cdc.gov/niosh/topics/default.html.
- 2.
Occupational Safety and Health Administration. Healthcare Standards. United States Department of Labor. Available from: https://www.osha.gov/SLTC/healthcarefacilities/standards.html.
- 3. Gausden E, Christ A, Zeldin R, Lane J, McCarthy M. Tracking Cumulative Radiation Exposure in Orthopaedic Surgeons and Residents: What Dose Are We Getting? The Journal of Bone and Joint Surgery. 2017;99: 1324–1329. pmid:28763418
- 4. Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? A Systematic review. Surg Endosc. 2013. pmid:23605191
- 5. Kracht J, Busch-Vishniac I, West J. Noise in the operating rooms of Johns Hopkins Hospital. The Journal of the Acoustical Society of America. 2007;121: 2673–2680. pmid:17550167
- 6. Epstein S, Sparer EH, Tran BN, et al. Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: A systematic review and meta-analysis. JAMA Surg. 2018. pmid:29282463
- 7. Patterson JM, Novak CB, Mackinnon SE, Patterson GA. Surgeons’ concern and practices of protection against bloodborne pathogens. Ann Surg. 1998;228: 266–272. pmid:9712573
- 8. Bernard JA, Dattilo JR, Laporte DM. The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution. J Surg Educ. 2013. pmid:24016379
- 9. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005. pmid:15712984
- 10. Soykut B, Erdem O, Akay C, Pişkin B. Investigation of the oxidative stress condition for occupational exposure to methyl methacrylate. Toxicol Ind Health. 2016. pmid:27449027
- 11. Schifilliti D, Mondello S, D’Arrigo MG, Chill G, Fodale V. Genotoxic effects of anesthetic agents: An update. Expert Opin Drug Saf. 2011. pmid:21595613
- 12. Kyriazanos I, Kalles V, Stefanopoulos A, Spiliotis J, Mohamed F. Operating personnel safety during the administration of Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Surg Oncol. 2016. pmid:27566037
- 13. Nwaiwu CA, Egro FM, Smith S, Harper JD, Spiess AM. Seroconversion rate among health care workers exposed to HIV-contaminated body fluids: The University of Pittsburgh 13-year experience. Am J Infect Control. 2017. pmid:28449921
- 14. Teschke K, Abanto Z, Arbour L, et al. Exposure to anesthetic gases and congenital anomalies in offspring of female registered nurses. Am J Ind Med. 2011. pmid:20607734
- 15. Anderson R, Sebaldt A, Lin Y, Cheng A. Optimal training frequency for acquisition and retention of high-quality CPR skills: A randomized trial. Resuscitation. 2019. pmid:30391370
- 16. Doomernik DE, van Goor H, Kooloos JGM, ten Broek RP. Longitudinal retention of anatomical knowledge in second-year medical students. Anat Sci Educ. 2017. pmid:27706913
- 17. Sharma GK, Gilson MM, Nathan H, Makary MA. Needlestick injuries among medical students: Incidence and implications. Acad Med. 2009;84:1815–1821. pmid:19940594
- 18. Makary MA, Al-Attar A, Holzmueller CG, et al. Needlestick injuries among surgeons in training. N Engl J Med. 2007;356: 2693–2699. pmid:17596603
- 19. Kennedy R, Kelly S, Gonsalves S, Mc Cann PA. Barriers to the reporting and management of needlestick injuries among surgeons. Irish journal of medical science. 2009;178: 297–299. pmid:19495835
- 20. Ford MT, Tetrick LE. Relations Among Occupational Hazards, Attitudes, and Safety Performance. Journal of occupational health psychology. 2011;16: 48–66. pmid:21280944
- 21. Vaisbuch Y, Aaron KA, Moore JM, et al. Ergonomic hazards in otolaryngology. Laryngoscope. 2019. pmid:30474217
- 22.
National Council on Radiation Protection and Measurement (NCRPM). Management of Exposure to Ionizing Radiation: Radiation Protection Guidance For the United States: Report No. 180.; 2018.
- 23. Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and Surgical Residents: Who Is Most at Risk? J Surg Educ. 2007. pmid:18063276
- 24. Choi LY, Torres R, Syed S, et al. Sharps and Needlestick Injuries Among Medical Students, Surgical Residents, Faculty, and Operating Room Staff at a Single Academic Institution. J Surg Educ. 2017.
- 25. Leggat PA, Smith DR, Kedjarune U. Surgical applications of methyl methacrylate: A review of toxicity. Arch Environ Occup Heal. 2009. pmid:19864224
- 26. Gendelberg D, Hennrikus W, Slough J, Armstrong D, King S. A radiation safety training program results in reduced radiation exposure for orthopaedic residents using the mini C-arm. Clin Orthop Relat Res. 2016 Feb; 474(2):580–4. pmid:26566977
- 27. Bowman J, Razi A, Watson S, et al. What leads to lead: Results of a nationwide survey exploring attitudes and practices of orthopaedic surgery residents regarding radiation safety. J Bone Joint Surg Am. 2018;100(3):e16 (1–7). pmid:29406352
- 28. Hasak JM, Novak CB, Patterson JMM, Mackinnon SE. Prevalence of Needlestick Injuries, Attitude Changes, and Prevention Practices over 12 Years in an Urban Academic Hospital Surgery Department. In: Annals of Surgery. 2018. pmid:28221166
- 29. McNichols CHL, Diaconu S, Alfadil S, et al. Cosmetic surgery training in plastic surgery residency programs. PRS Glob Open. 2017;5(9): e1491. pmid:29062658
- 30. Shah MD, Johns MM, Statham M, Klein AM. Assessment of phonomicrosurgical training in otolaryngology residencies: a resident survey. Laryngoscope. 2013;123(6): 1474–1477. pmid:23568536