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PSNet: Patient Safety Network
Journal Article
Study

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.

Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ quality & safety. 2019;28:276-283.

This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.