Where are my instruments? Hazards in delivery of surgical instruments.
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.



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.



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.



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.
Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands. A.C.P.Guedon@tudelft.nl.
Annetje C P
AC
Guédon
Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
Linda S G L
LS
Wauben
Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
Anne C
AC
van der Eijk
Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
Alex S N
AS
Vernooij
Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
Frédérique C
FC
Meeuwsen
Reinier de Graaf Groep, Reinier de Graafweg 3-11, 2625 AD, Delft, The Netherlands.
Maarten
M
van der Elst
Reinier de Graaf Groep, Reinier de Graafweg 3-11, 2625 AD, Delft, The Netherlands.
Vivian
V
Hoeijmans
Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
Jenny
J
Dankelman
Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
John J
JJ
van den Dobbelsteen
D000067495:Healthcare Failure Mode and Effect Analysis; D006761:Hospitals; D006801:Humans; D008490:Medical Informatics; D009873:Operating Rooms / Q000458:organization & administration*; D009934:Organization and Administration; D018570:Risk Assessment; D013242:Sterilization / Q000458:organization & administration*; D013525:Surgical Instruments / Q000600:supply & distribution*
Information technology; Logistics; Risk analysis; Safety; Surgical instruments