Where are my instruments? Hazards in delivery of surgical instruments

Background Unavailability of instruments is recognised to cause delays and stress in the operating room, which can lead to additional risks for the patients. The aim was to provide an overview of the hazards in the entire delivery process of surgical instruments and to provide insight into how Information Technology (IT) could support this process in terms of information availability and exchange. Methods The process of delivery was described according to the Healthcare Failure Mode and Effects Analysis methodology for two hospitals. The different means of information exchange and availability were listed. Then, hazards were identified and further analysed for each step of the process. Results For the first hospital, 172 hazards were identified, and 23 of hazards were classified as high risk. Only one hazard was considered as ‘controlled’ (when actions were taken to remove the hazard later in the process). Twenty-two hazards were ‘tolerated’ (when no actions were taken, and it was therefore accepted that adverse events may occur). For the second hospital, 158 hazards were identified, and 49 of hazards were classified as high risk. Eight hazards were ‘controlled’ and 41 were ‘tolerated’. The means for information exchange and information systems were numerous for both cases, while there was not one system that provided an overview of all relevant information. Conclusions The majority of the high-risk hazards are expected to be controlled by the use of IT support. Centralised information and information availability for different parties reduce risks related to unavailability of instruments in the operating room.