A Proactive Risk Assessment Framework to Enhance Patient Safety: Analysis of Unintended Retained Foreign Objects in Operating Rooms

Abstract

According to a study by Johns Hopkins, in average 251,454 Americans die annually from preventable medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Among different adverse events in healthcare settings, unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. The risk assessment framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the Nuclear Regulatory Commission, with an accident investigation framework called AcciMap, originally developed by Rasmussen. The AcciMap is a hierarchical framework, which comprises six layers: government and regulatory bodies, company, management, staff and work. In this study, it has been utilized to capture and analyze socio-technical contributing causes of URFOs across its layers in order to assess the activities of key players in each layer as well as the interactions between those layers. Moreover, we have been able to identify the most influential traits of a positive safety culture affecting the URFOs issue.

The implementation framework of active risk management in the operating rooms of hospitals in the country: A qualitative study in Iran

“…The occurrence of errors and adverse events is due to the lack of e cient management and other technical, human, and organizational failures (e.g., lack of proper communication and training, as well as a lack of adequate standard procedures). These cases have led to issues such as wrong site surgery, wrong procedure, and wrong anesthesia management, which are signi cant in operating rooms, putting patients' lives at risk and imposing huge costs on healthcare systems (14).…”

“…Also, about a third of the events cause harm to the patient, which can vary from increasing the length of stay to death (16). Prevention and reducing errors and adverse events in the operating room can increase the quality of care (14).…”