University of Twente Student Theses


Het effect van equipment gerelateerde incidenten op de continuïteit van het primaire zorgproces op de OK

Wubben, Ingmar (2009) Het effect van equipment gerelateerde incidenten op de continuïteit van het primaire zorgproces op de OK.

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Abstract:Background: Equipment related incidents in the operating room (OR) occur frequently and might affect the patient, employee, or the continuity of the care process. The objective of this study was to determine the occurrence of equipment related incidents and the effect on the continuity of the care process in a large teaching hospital. Methods: During a four week registration period, OR nurses were asked to fill in a registration form for every surgery procedure performed in a clinical OR. When multiple incidents occurred, a form was filled for each incident. On this form they registered whether or not an equipment related incident occurred and gave details about the incident, the consequences, and possible causes. A structured analysis (PRISMA) was used to analyze incidents that resulted in serious delays (>15 minutes). Results: Registration forms were returned for 911 out of 1580 surgery procedures (57,7%). In total 148 incidents were registered in 933 forms (15,9%), which resulted in a total of 29 hours and 45 minutes of extra work. In addition, 12 hours and 9 minutes of delay in procedures were registered. Most incidents involved instruments (68) or medical devices (42). Furthermore, most incidents occurred during the surgery procedure (101) whereas considerably less incidents occurred during the preparation phase (47). None of the incidents resulted in direct damage for the patient, although indirect damage like longer anesthesia (29) or postponed procedures (2) did occur. 10% of the registered incidents were classified as “serious” and caused 60% of the registered delay. For these serious incidents, “management decisions” (e.g. inventory capacity, planning procedure) was the most encountered root‐cause. Conclusions: Equipment related incidents occurred frequently in the ORs of the involved hospital sites(up to 15,9%) and resulted on average in 12 minutes of extra work and 5 minutes of delay per event. Management decisions concerning inventory capacity planning have a great influence on the consequences of equipment related incidents. Preventive activities for the studied hospital should focus on re‐evaluating these decisions. Furthermore, we found a serious underreporting of incidents as only 6 out of the 148 incidents in this study were found in the blame free reporting database.
Item Type:Essay (Master)
Isala klinieken
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:85 business administration, organizational science
Programme:Industrial Engineering and Management MSc (60029)
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