Table 2 Summary of qualitative contributing factor analysis
Definition | Case characteristics | Takeaways |
|---|---|---|
Incomplete preoperative verification | ||
Surgery performed without adherence to components of a preoperative protocol expected for the intended surgery | - Did not confirm the nature of surgery with patient - Did not confirm site of surgery with patient - Did not confirm implant with patient - Did not confirm instrument setting, measurement, preoperative calculation - Did not appropriately mark the site of surgery - Did not conduct an adequate informed consent discussion | - Adapt a validated preoperative protocol to fit office practice (e.g. Universal Protocol, WHO Surgical Safety Checklist) - Confirm identity, site, implants & surgery with patient - Review the informed consent form with the patient - Involve operating physician & patient in site marking & draping - Continuously audit preoperative protocol, update as required |
Inadequate intraoperative surgical count | ||
Surgery was completed prior to the completion of a comprehensive instrument, needle, or sponge count | - Surgical count was not performed - Surgical count was performed incorrectly - Surgical count was incomplete (no preoperative or postoperative count) - Surgical count did not include an instrument or tool utilized during the surgery | - Adapt a validated preoperative protocol to fit office practice (e.g. Universal Protocol, WHO Surgical Safety Checklist) - Ensure that every instrument or tool utilized during the surgery is included in the count - File all surgical documentation in patient medical records - Complete a sufficient intra-operative assessment of the incision prior to closure |
Foreign object was retained but there was no instrument, needle, or sponge count included in the patient’s files | ||
Insufficient review of patient medical record before procedure | ||
Surgery began without the surgeon and/or clinical team reviewing pre-operative documentation pertinent to the current surgery | - Did not review preop consultation note to confirm nature of surgery - Did not review preop consultation note to confirm site of surgery - Did not review preop consultation note to confirm the implants - Did not review preop consultation note to confirm instrument setting, measurement, preop calculation - Preop consultation note was incomplete or lacking the detail necessary for lesion localization - Preop consultation note was not accessible | - Conduct a thorough preoperative consultation and document necessary details. File preoperative note in patient medical record - Confirm the identity, site, implants and surgical procedure by reviewing the patient medical record - Do not perform the surgery without the required medical records |
A preoperative consultation note was reviewed but did not contain sufficient information to safely complete the surgery | ||
Surgery performed without the necessary resources | ||
Surgery performed without the necessary surgical instruments, equipment, or staffing | - Trained staff were not available to support surgery - Surgery was performed without any nursing assistance - Medical equipment required for the surgery was not available in the office - Medical equipment required for unexpected complications were not available in the office | - Maintain appropriate staffing levels - If required, operate with nursing assistance - Confirm that the equipment required for the surgery is available in the operating room space - Confirm access to additional equipment that may be required during unexpected complications |
Administrative error or office disorganization | ||
Surgery was performed based on an error in the patient’s records or office-booking system | - Transcription error (typographic error, illegible handwriting) resulting in the wrong measurement or preop calculation being used - Transcription error (typographic error, illegible handwriting) resulting in the wrong implant being used - Preop consultation note was not found in time for procedure - Erroneous appointment booking title - No protocol in place to confirm and manage inventory shipments | - Double check all measurements and implant specifications prior to scheduled surgery - Create detailed and accurate appointment booking titles and confirm booking title prior to scheduled procedure - Implement a policy to confirm and track shipments to ensure correct implant prior to procedure |
Office record keeping and inventory management practices were inadequate compared to industry standards | ||