Evidence map›Paper›PMID 39400864›Full record

SynthesisIrish journal of medical science2025

What is known about near miss events in the operating room? A systematic review of studies of mixed methods design.

Ruth Kavanagh, Marie E Ward

Abstract readSystematic Review
PubMed Publisher
In one paragraph

Synthesis in Irish journal of medical science, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
3citing papers in PubMed, 1 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

3 citing papers in PubMed, 1 synthesis or guideline pooled it.

  1. Pooled it
  2. Article
  3. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

2 authors.

Ruth KavanaghBeaumont Hospital, Ireland & Royal College of Surgeons Ireland, Dublin, Ireland.
Marie E WardHealth Systems Research, St James's Hospital and Centre for Innovative Human Systems, Trinity College, the University of Dublin, Dublin, Ireland. marie.ward@tcd.ie.ORCID http://orcid.org/0000-0002-6638-8461

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

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. DISCUSSION: The implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.

Indexed as

Medical ErrorsNear Miss, HealthcareOperating RoomsPatient SafetyHumansHuman Factors ErgonomicsNear miss eventsOperating roomSerious harm

Identifiers

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.