5 Red Flags in Surgical Positioning Injuries: What the Operative Record May Reveal

An unexpected postoperative injury raises important questions. Does the perioperative record provide the answers?

A patient enters the operating room without a documented neurological deficit and awakens following surgery with numbness, weakness, or an unexpected pressure injury.

Was the injury related to surgical positioning? Could it have been prevented? What information should be available in the medical record to help reconstruct what occurred?

Surgical positioning is more than a technical requirement to provide access to the operative site. It is an essential component of perioperative patient safety.

During general anesthesia, patients are unable to independently reposition themselves or communicate discomfort. Anesthetic effects may also impair normal protective responses. The perioperative team must therefore consider the patient's individual risks, the surgical procedure, positioning equipment, and appropriate protective measures.

The Operating Room Nurses Association of Canada (ORNAC) publishes evidence-informed guidelines for perioperative practice in Canada. These guidelines provide an important professional resource for evaluating perioperative processes, including patient safety considerations.

As a Legal Nurse Consultant with a background in perioperative nursing, I examine not only whether an injury occurred, but what the complete clinical record reveals about the care provided.

Here are five red flags I look for when reviewing potential surgical positioning injuries.

🚩 1. Incomplete Preoperative Positioning Risk Assessment

Not every patient has the same risk of developing a positioning-related injury.

Pre-existing neurological conditions, diabetes, vascular impairment, reduced mobility, joint limitations, obesity, nutritional status, and compromised skin integrity may influence positioning-related risks.

The assessment should also consider the anticipated procedure, surgical position, and expected duration.

What I look for:

• Missing or incomplete baseline skin or neurological assessments when clinically indicated.

• Identified risk factors without evidence that they were considered in positioning decisions.

• Pre-existing mobility restrictions or musculoskeletal limitations not reflected in the care plan.

• Lack of documented communication regarding special positioning requirements.

• Inconsistencies between the preoperative assessment and intraoperative positioning documentation.

Why it matters

Establishing the patient's baseline condition is important when evaluating an unexpected postoperative finding.

For example, a patient who reports new hand weakness following surgery may require a review of pre-existing neurological symptoms, intraoperative arm positioning, surgical factors, and subsequent assessments.

Without adequate baseline information, it can become difficult to determine whether a finding was present before surgery or developed afterward.

A missing assessment does not establish that an injury was preventable, but it may limit the ability to reconstruct the clinical circumstances.

🚩 2. Inadequate Documentation of Positioning and Protective Measures

The intraoperative nursing record should provide a meaningful account of how the patient was positioned and what precautions were taken.

Depending on the procedure, positioning may involve arm boards, padding, stirrups, head supports, positioning straps, or other specialized equipment.

The objective is to provide surgical access while minimizing avoidable pressure, nerve compression, excessive joint movement, and other positioning-related risks.

What I look for:

• Incomplete documentation of the surgical position.

• Missing information regarding positioning devices or protective padding.

• Unclear positioning of the upper or lower extremities.

• Failure to document clinically significant position changes.

• Differences between the nursing record and anesthesia documentation.

• Positioning details that appear inconsistent with the procedure performed.

Why it matters

An operative record that states only "supine" or "lithotomy" may not provide sufficient information to understand the specific precautions used when a positioning-related injury is being investigated.

For example, when reviewing an alleged peripheral nerve injury, details about arm placement, support, and positioning changes may be particularly relevant.

However, the absence of a documented intervention does not automatically establish that the intervention was not performed.

The reviewer must consider the complete record, applicable institutional policies, and information from other members of the surgical team.

🚩 3. Prolonged Procedures Without Evidence of Appropriate Reassessment

Duration of surgery is an important factor when evaluating certain positioning-related complications.

Prolonged immobility, sustained pressure, and positioning-specific physiological effects may increase injury risk, particularly in patients with additional vulnerabilities.

Some surgical procedures also extend unexpectedly because of complications, technical difficulties, or changes in the operative plan.

What I look for:

• Extended operative times without evidence of reassessment when clinically indicated.

• Unexpected delays that significantly increase time in a particular position.

• Changes in surgical positioning without corresponding documentation of protective measures.

• Documented concerns regarding pressure, circulation, or positioning without clear follow-up.

• Limited communication about positioning concerns during prolonged procedures.

Why it matters

The longer a patient remains in a fixed position, the more important it may become to consider the cumulative effects of pressure and immobility.

However, reassessment or repositioning must be considered within the realities of the procedure.

Sterile field requirements, surgical exposure, patient stability, and operative conditions may affect when and how adjustments can safely occur.

A prolonged procedure is not, by itself, evidence of inappropriate care.

The question is whether reasonable precautions and assessments were appropriate for that patient's circumstances.

🚩 4. Postoperative Neurological or Skin Findings Without Adequate Follow-Up

Positioning-related injuries are not always immediately apparent.

Some patients report symptoms during early recovery, while others recognize changes later, once anesthetic effects have resolved and mobility increases.

Potential concerns may include sensory disturbances, muscle weakness, localized pain, skin discoloration, or pressure injuries.

What I look for:

• New numbness, tingling, weakness, or altered sensation after surgery.

• Unexpected skin breakdown, redness, bruising, or pressure-related findings.

• Patient complaints without documented assessment or appropriate escalation.

• A lack of follow-up when neurological or skin findings persist.

• Differences between PACU documentation and later nursing or physician assessments.

Why it matters

The location, onset, severity, and progression of symptoms may help identify possible injury mechanisms.

For example, postoperative upper-extremity weakness may raise questions about positioning, but other explanations must also be considered.

These may include pre-existing neuropathy, direct surgical injury, regional anesthesia, vascular compromise, or unrelated neurological conditions.

Identifying an injury is only the beginning of the analysis.

Determining its cause may require a careful clinical chronology, diagnostic findings, and input from appropriately qualified medical specialists.

🚩 5. Discrepancies Between the Operative Record and Subsequent Clinical Findings

A potential positioning injury cannot always be understood by examining the intraoperative nursing record alone.

Important information may be distributed across several documents, including:

• Preoperative nursing assessments.

• Anesthesia records.

• Intraoperative nursing documentation.

• Operative reports.

• PACU assessments.

• Postoperative progress notes.

• Specialist consultations and diagnostic investigations.

What I look for:

• Conflicting descriptions of the patient's position.

• Differences in documented procedure duration or positioning changes.

• A lack of continuity between an intraoperative concern and subsequent clinical assessments.

• Unexpected neurological findings without a clear clinical timeline.

• Missing or inconsistent information about when symptoms were first identified.

Why it matters

Individual records may contain accurate information while still failing to communicate the complete clinical picture.

For example, an anesthesia record may identify a position change that is not clearly reflected in the nursing record.

Alternatively, postoperative documentation may reveal a new clinical finding that requires closer examination of the earlier operative events.

These discrepancies do not establish negligence, but they may identify important areas for further investigation.

Looking Beyond the Injury: The Legal Nurse Consultant's Perspective

When reviewing a potential surgical positioning injury, the objective is not simply to identify missing documentation.

It is to reconstruct the patient's clinical experience and examine whether the available evidence supports the allegations being considered.

My review focuses on several questions:

What was the patient's condition before surgery?

Were relevant neurological, vascular, skin, and musculoskeletal concerns identified?

What positioning precautions were used?

Does the record provide sufficient information to understand how the patient was positioned and protected?

What happened during the procedure?

Were there significant delays, position changes, complications, or other events that could have influenced injury risk?

When was the injury first recognized?

Does the timing and pattern of clinical findings suggest a plausible positioning-related mechanism?

What standards and policies applied?

Were the relevant ORNAC guidelines, organizational policies, regulatory expectations, and other professional resources considered in the context of the care provided?

These questions are relevant to both plaintiff and defence counsel.

For plaintiff counsel, a structured review may help identify concerns requiring additional investigation or expert opinion.

For defence counsel, the same analysis may help establish that appropriate precautions, assessments, and interventions were undertaken, or identify alternative explanations for an unexpected clinical outcome.

Importantly, an unexpected surgical injury does not automatically establish a breach of the standard of care.

The presence of an injury, the appropriateness of care, and whether any identified departure caused the injury are separate questions requiring individual consideration.

Canadian Professional Guidelines and Documentation Standards

In Canada, the ORNAC Guidelines for Perioperative Practice in Canada, 17th Edition (2025) provide evidence-informed recommended practices for perioperative nursing and surgical services.

The guidelines support professional decision-making and are commonly used as resources in developing organizational policies and procedures.

The British Columbia College of Nurses and Midwives (BCCNM) also establishes nursing documentation expectations, including accurate and timely recording of assessments, interventions, communication, and outcomes.

Although professional guidelines and regulatory standards serve different functions, both may be relevant when examining the clinical care and documentation involved in an alleged surgical positioning injury.

For retrospective medical record review, it is essential to identify the standards, policies, and professional expectations that applied at the time of the care, rather than automatically applying current publications to historical events.

The Bottom Line

Surgical positioning is a collaborative patient safety responsibility requiring clinical judgment, careful planning, communication, and appropriate protective measures.

When an unexpected postoperative injury occurs, the medical record may provide important information about what happened, what precautions were taken, and whether additional investigation is warranted.

The most meaningful findings often emerge when the entire perioperative record is reviewed rather than relying on a single nursing note or operative report.

A red flag is not proof of negligence. It is a reason to look deeper.

References

1. Operating Room Nurses Association of Canada (ORNAC). (2025). Guidelines for Perioperative Practice in Canada (17th ed.).

Official publication information and purchasing options:

https://ornac.ca/guidelines.phtml

Canadian perioperative practice reference. The full publication is available through CSA Group.

2. Operating Room Nurses Association of Canada (ORNAC). (2025). Now available: ORNAC Guidelines for Perioperative Practice in Canada, 17th Edition! ORNAC Journal, 42(1), 27.

https://ornacjournal.ca/index.php/ornac/article/view/14507

3. British Columbia College of Nurses and Midwives (BCCNM). (2026). Nurses: Documentation. Practice Standard.

https://www.bccnm.ca/rn/PracticeStandards/Pages/documentation.aspx

4. British Columbia College of Nurses and Midwives (BCCNM). Documentation in Nursing Practice.

https://www.bccnm.ca/RN/learning/documentation/Pages/Default.aspx

5. McLellan, M. (1989). Patient positioning: A ready-reference guide. Operating Room Nurses Association of Canada Journal, 7(5).

https://ornacjournal.ca/index.php/ornac/article/view/13167

Historical Canadian perioperative nursing reference. Included for background, not as a representation of current positioning guidance.

About the Author

Rhonda Winter, RN, MBA (Candidate)
Legal Nurse Consultant | Rhonda Winter Consulting

Drawing on her nursing experience in PeriAnesthesia, perioperative care, and healthcare operations, Rhonda provides medical record reviews and clinical analysis to legal professionals.

Her clinical perspective supports the identification of documentation concerns, reconstruction of complex care timelines, and examination of care in the context of relevant professional standards.

Website: https://rhondawinterconsulting.ca

Disclaimer: This article is intended for educational and informational purposes only. The identification of a clinical or documentation red flag does not establish negligence, causation, or legal liability. Individual cases require examination of the complete clinical record, applicable standards at the time of care, and opinions from appropriately qualified experts.