American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Errors in the OR: Studies look at when and why

OCTOBER 26, 2017
Clinical Congress Daily Highlights, Thursday Edition

Mistakes in the operating room (OR) can be fatal — research that helps minimize or detect them has the potential to save countless lives.

Two studies presented this week examined OR errors – one to see if they are more frequent during nighttime operations and the other to test an innovative camera-and-microphone system as a more sensitive method to spot the sources of adverse events.

A team led by Trine G. Eskesen, Massachusetts General Hospital, Boston, MA, found that operating at night does not correlate with increased risk of intraoperative adverse events (iAEs). The authors reviewed their institution’s 2007-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and administrative databases, screening for iAEs using the ICD-9-CM-based Patient Safety Indicator “Accidental Puncture/Laceration.” They found 9,136 surgical procedures, 7,445 (81.5 percent) occurring in the morning (AM), 1,303 (14.3 percent) in the afternoon (PM) and 388 (4.3 percent) at night. The researchers found iAEs in 183 procedures, but determined there was no difference in their occurrence among the AM, PM, and night patients. The authors conclude that restricting nighttime operating might not improve patient safety and might increase cost.

James Jung, MD, University of Toronto, ON, and his colleagues found that a multiport synchronized recording system called the Operating Room Black Box (ORBB) enabled prospective, reliable, and detailed assessments of technical performance and environmental and organizational factors. The researchers also showed that the average OR is a very distracting environment. Two analysts reviewed 129 recordings of elective laparoscopic procedures and noted what they saw and heard. On average, the cases were 83.8 minutes long and were disrupted once every 75 seconds by opening OR doors, ringing telephones, buzzing pagers, and loud noises. Most of the 1,181 intra-operative events were inadvertent bleeding.

Additional Information:
These Scientific Forum studies were presented at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at

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