Equipment-related incidents in the operating room: An analysis of occurrence, underlying causes and consequences for the clinical process

Quality and Safety in Health Care

Volumn 19, Issue 6, 2010, Pages

  Wubben, I ^a   Van Manen, J G ^a   Van Den Akker, B J ^b   Vaartjes, S R ^c   Van Harten, W H ^a  

^a UNIVERSITY OF TWENTE   (Netherlands)

^b ISALA HOSPITAL   (Netherlands)

^c MEDISCH SPECTRUM TWENTE   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; EQUIPMENT; HEALTH CARE QUALITY; HUMAN; MEDICAL INSTRUMENTATION; NETHERLANDS; OPERATING ROOM; STANDARD; TEACHING HOSPITAL;

DURABLE MEDICAL EQUIPMENT; EQUIPMENT FAILURE; HOSPITALS, TEACHING; HUMANS; NETHERLANDS; OPERATING ROOMS; QUALITY OF HEALTH CARE;

EID: 78650378905     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2009.037515     Document Type: Article

References (26)

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To err is human: Building a safer health system. Washington, DC: National Academy Press, 2000.
2. Zegers M, De Bruijne MC, Wagner C, et al. Adverse events and potentially preventable deaths in Dutch hospitals: Results of a retrospective patient record study. Quality and Safety in Health care. 2009;18:297-302.
3. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary retrospective record review. BMJ 2001;322:517-9.
4. Zegers M. Adverse events among hospitalized patients: Results and methodological aspects of a record review study. Amsterdam: Free University, 2009.
5. Thomas AN, Galvin I. Patient safety incidents associated with equipment in critical care: A review of reports to the UK national patient safety agency. Anaesthesia 2008;63:1193-7.
6. Bhasale AL, Graeme C, Miller C, et al. Analysing potential harm in Australian general practice: An incidentemonitoring study. Med J Aust 1998;169:73-6.
7. Cullen D, Bates D, Small S, et al. The incident reporting system does not detect adverse events: A problem for quality improvement. Jt Comm J Qual Improv 1995;21:541-8.
8. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 1984;60:34-42.
9. Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: A study of human factors. Qual Saf Health Care 2002;11:277-82.
10. Reason J. Human error: Models and management. BMJ 2000;320:768-70.
11. Dutch Healthcare Inspectorate (IGZ). Kwaliteitsborging van medische apparatuur in ziekenhuizen: Verbeteringen noodzakelijk. 2002.http://www.igz.nl/ 15451/96651/ rapport-medische-apparatuur1.pdf (Accessed 15 Apr 2009). (Dutch).
12. Dutch Healthcare Inspectorate (IGZ). Kwaliteitsborging van medische apparatuur in ziekenhuizen: Nog steeds onderschat. 2005 http://www.igz.nl/15451/ 17873/ Rapport-2005e12-Kwaliteitsb1.pdf (Accessed 15 Apr 2009). (Dutch).
13. Anon. Nederlandse Vereniging van Ziekenhuizen (NVZ) Praktijkgids Risicomanagement en Medische technologie (Practice guide on Riskmanagement and Medical Technology 2007 http://www.nvzeziekenhuizen.nl/dsresource? objectid=43994&type=org (Dutch).
14. Hamilton DM, Breslawski S. Operating room scheduling: Factors to consider. AORN J 1994;59:665-80.
15. Overdyk FJ, Harvey SC, Fishman RL, et al. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg 1998;86:896-906.
16. Grudich G. The critical path system: The road towards an efficient OR. AORN J 1991;53:705-14.
17. Moss JRN, Xiao Y. Improving operating room coordination: Comunication pattern assessment. JONA 2000;34:93-100.
18. Healy AN, Sevdalis N, Vincent CA. Measuring intraeoperative interference from distractions and interruption observed in the operating theatre. ergonomics 2006;49:589-604.
19. Grundgeiger T, Sanderson P. Interruptions in healthcare: Theoratical views. Int J Med Inform 2000;78:293-307.
20. Hickam D, Severance S, Feldstein A, et al. The effect of health working conditions on patient safety. Rockville. MD: Agency for Healthcare Research and Quality, 2003 03-E031.
21. Vuuren van W, Shea CS. Schaaf van der TW van der. The development of an incident analysis tool for the medical field. eindhoven: Technical University, 1997.
22. Schaaf van der TW, Habraken MMP. PRISMAeMedical: A brief description. eindhoven: Technical University, 2005.
23. Zegers M, Bruijne de MC, Wagner C, et al. Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals. BMC Health Serv Res 2007,7:27 doi: 10.1186/1472e6963e7e27.
24. Thomas eJ, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med 2002;136: 812-6.
25. Wolff A, Bourke J. Reducing medical error: A practical guide. Med J Aust 2000;173:247-51.
26. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N engl J Med 2009;360:491-9.