Unseen risks in the operating room: A study of environmental and system-related intraoperative adverse events

IF 1 Q2 Nursing

Perioperative Care and Operating Room Management Pub Date : 2026-03-01 Epub Date: 2026-01-10 DOI:10.1016/j.pcorm.2026.100613

Sergio Susmallian , Martine Szyper-Kravitz

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引用次数: 0

Abstract

Background

The operating room (OR) is a highly complex environment where human, technical, and system interactions can generate intraoperative adverse events (IAEs) unrelated to direct surgical errors. This study aimed to evaluate IAEs arising from environmental, human, and system-related factors and to assess their impact on patients, staff, and surgical specialties.

Material and Methods

A retrospective observational study was conducted at a tertiary hospital between 2014 and 2020. Eighty-two cases of IAEs were identified from 559,910 surgical procedures through institutional Safety and Risk Management investigations, excluding “never events” and direct surgical errors. Data on incident type, surgical specialty, affected party, causative classification (human, system, or patient-related), and demographics were analyzed. Statistical analysis was performed using IBM SPSS Statistics, with significance set at p < 0.05.

Results

The mean age of the cohort was 61.22 ± 18.52 years, and 46 (51.1%) were male. Of all incidents, 67 (81.7%) affected patients and 15 (18.3%) involved OR personnel. General surgery accounted for 35.4% of cases. Human-related causes predominated (54.9 %), followed by system-related (29. %) and patient-related (15. %) factors (p < 0.001). System-related incidents occurred more often among older patients (mean 68.3 vs. 56.0 years; p = 0.013). No significant association was observed between incident type and surgical specialty (p = 0.188).

Conclusion

Environmental and system-related IAEs constitute an underrecognized yet preventable source of harm in surgical care. Human factors remain the leading cause, underscoring the need for standardized safety protocols, routine equipment maintenance, and multidisciplinary team training to strengthen OR safety culture.

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手术室中看不见的风险：与环境和系统相关的术中不良事件研究

手术室（OR）是一个高度复杂的环境，其中人员、技术和系统的相互作用可能产生与直接手术错误无关的术中不良事件（iae）。本研究旨在评估由环境、人为和系统相关因素引起的肠内感染，并评估其对患者、工作人员和外科专业的影响。材料与方法2014 - 2020年在某三级医院进行回顾性观察性研究。通过机构安全和风险管理调查，从559,910例外科手术中确定了82例iae，排除了“从未发生的事件”和直接手术错误。分析了事件类型、外科专科、受影响方、病因分类（人、系统或患者相关）和人口统计学数据。采用IBM SPSS Statistics进行统计学分析，p <； 0.05为显著性。结果患者平均年龄为61.22±18.52岁，男性46例（51.1%）。在所有事件中，67例（81.7%）影响患者，15例（18.3%）涉及手术室人员。普通外科占35.4%。人为原因占多数（54.9%），其次是系统原因（29.9%）。%)和患者相关（15%）。%)因素（p < 0.001）。系统相关事件在老年患者中更常见（平均68.3岁vs. 56.0岁；p = 0.013）。事件类型与手术专科无显著相关性（p = 0.188）。结论环境和系统相关的iae是外科护理中一个未被充分认识但可预防的危害来源。人为因素仍然是主要原因，因此需要标准化的安全协议、日常设备维护和多学科团队培训来加强手术室的安全文化。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Perioperative Care and Operating Room Management Nursing-Medical and Surgical Nursing

CiteScore

1.30

自引率

0.00%

发文量

审稿时长

56 days

期刊介绍： The objective of this new online journal is to serve as a multidisciplinary, peer-reviewed source of information related to the administrative, economic, operational, safety, and quality aspects of the ambulatory and in-patient operating room and interventional procedural processes. The journal will provide high-quality information and research findings on operational and system-based approaches to ensure safe, coordinated, and high-value periprocedural care. With the current focus on value in health care it is essential that there is a venue for researchers to publish articles on quality improvement process initiatives, process flow modeling, information management, efficient design, cost improvement, use of novel technologies, and management.