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Spencer Robertson is a 4-week-old frail neonate who had a rectal exam and dilatation under anesthesia following prior surgery for imperforate anus.When the drapes were removed from Spencer,the perioperative nurse noted an area of redness,swelling,and abrasions on the buttocks of the patient.Spencer had been positioned prone for 20 minutes.The nurse who noted the skin condition had relieved the circulating nurse and quickly reviewed the perioperative record and patient chart,but had not seen the patient before positioning.Which of the following safety factors may have contributed to this event?
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