“…Preoperative planning Inadequate laboratory tests and imaging prior to surgery (7,24,25,27) Anaesthetic period Inconsistent anaesthetic/sedation protocol, medication and equipment used (7,13,(20)(21)(22)(23)26), delayed anaesthetic pre-evaluation and preparation (19,20) Paperwork Incomplete (i.e., delay in obtaining patient consent) (13,20,23), excess paperwork (24), redundant paperwork (21,22,28) Instrument trays Delay in preparation of instrument trays (13,19,20,27), inadequate availability of instruments (13,20,27), delay in instrument processing (20,27) Surgeons Late arrival to OT (20,28), delayed pre-evaluation (21), supervision of trainees (15,16) Steps in process Re-performing steps (15), step(s) with highest time variance (7,14,(16)(17)(18)24,25), longest operation step (14,17,18), variable number/type/sequence of steps to complete a task …”