Operating rooms are high-risk healthcare settings. A new study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) and discuss recommendations for safer healthcare systems.
For the study, researchers searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as “serious” with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management.
The study found multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.
- A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach. Journal of Patient Safety. June 2022.