Perioperative patient safety: nurses’ safety perceptions and observed compliance with safety standards in the operating room

BACKGROUND: Perioperative patient safety remains a major concern, as a substantial proportion of adverse events occur in surgical settings. Ensuring safe surgical care requires not only a strong safety culture among healthcare professionals but also good adherence to established safety standards. Nurses play a central role in maintaining perioperative safety in the operating room (OR). This study aims to assess perioperative compliance with established safety standards across all phases of surgical care, evaluate perioperative nurses' safety perceptions, and identify the factors associated with these perceptions. METHODS: An analytical cross-sectional observational study was conducted in the OR of two university hospitals in Tunisia. An exhaustive sample of all perioperative nurses working in ten OR was targeted. Their perception of patient safety was assessed using a single-item measure adapted from the Hospital Survey on Patient Safety Culture (HSOPSC). Compliance with perioperative safety standards was evaluated through direct observation of a sample size of 266 surgical procedures, using the validated Surgical Patient Safety Observation Tool (SPOT). Descriptive and inferential statistical analyses were performed. All ethical considerations were respected. RESULTS: The majority of perioperative nurses rated patient safety in their units as good. Safety training (p = 0.020), regular protocol updates (p = 0.003), and effective communication (p = 0.018) were significantly associated with higher perceived safety. However, observational audit findings demonstrated that none of the SPOT dimensions reached the 90% threshold for good compliance, and the overall compliance with safety standards remained below 60%, indicating persistent weaknesses in perioperative safety practices. Communication and handover demonstrated the highest compliance (59%), whereas infection prevention was the lowest (36.5%). CONCLUSIONS: Although perioperative nurses reported generally favorable perceptions of patient safety, observed compliance with safety standards remained poor, highlighting a clear perception-practice gap. Key organizational factors, particularly safety training, regular protocol updates, and effective communication, were significantly associated with higher perceived safety. These findings stress the need for targeted, systemic interventions aimed at strengthening training, improving protocol dissemination, enhancing handover processes, and reinforcing infection prevention and surgical counting practices to improve perioperative patient safety.