• Ruth Kavanagh and Marie E Ward.
• Beaumont Hospital, Ireland & Royal College of Surgeons Ireland, Dublin, Ireland.
• Ir J Med Sci. 2024 Oct 14.

BackgroundA near miss event (NME) in healthcare is an event that did not happen but would have caused serious harm if it did. The operating room (OR) is prone to risk and incidents, with estimates that 50% of all hospital adverse events occur in the OR, yet reporting of NME is uncommon in the OR.ObjectiveTo carry out a systematic review of studies with mixed methods to establish what is known about NME reporting in the OR.MethodInclusion criteria will be those studies of mixed methods design, which have been conducted in the OR, with teams of surgeons, anaesthetists or nurses alone or in any combination. Using a publication timeframe of 2001-2023, the following databases were searched: Medline (OVID), CINAHL, Pubmed and Google Scholar. Selected papers for the review were assessed using the Quality Assessment Tool for Studies of Diverse Designs.ResultsFourteen papers were included in the review. NMEs are common occurrences that are underreported in the OR. When NMEs occur in multiples for the same patient, the risk of serious harm increases. Feedback and education about NME helps to improve reporting; ORs with high rates of NME reporting have less serious patient harm events.DiscussionThe implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.© 2024. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.

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