PRISMA profile of the 15 ‘serious’ incidents21 22*
| Root-causes identified in PRISMA analysis21 22 | No | Examples from related study |
| Technical | ||
| T-ex (External) | – | |
| TD (Design) | 2 | Malfunctioning software in navigation equipment |
| TC (Construction) | – | |
| TM (Materials) | 5 | Scope made of fibreglass is internally broken |
| Organisational | ||
| O-ex (External) | 1 | No intensive care bed available for patient that needs other type of surgery (intensive care and operating room are separately managed department) |
| OK (Transfer of Knowledge) | – | |
| OP (Protocols) | 2 | Multiple types of video carts are available. Surgeons prefer a certain type and use this one when available, even if they can perform the surgery with an older type. Now, another surgery that needed this specific video cart was delayed by the unavailability (lack of procedures). |
| OM (Management priorities) | 13 | Decision to do five identical procedures in 1 day, while only three sets are available. Delay in sterilisation process causes delays in the operating room. |
| OC (Culture) | – | |
| Human | ||
| H-ex (external) | 4 | Surgical instruments are missing in instrument set (human error in sterilisation department) |
| HKK (Knowledge) | – | |
| HRQ (Qualifications) | – | |
| HRC (Coordination) | 2 | Surgeon decides to perform other type of surgery when patient is already in the operating room (equipment was not available yet) |
| HRV (Verification) | – | |
| HRI (Intervention) | 7 | Wrong use of instrument resulted in broken screws |
| HRM (Monitoring) | 2 | Operating room nurse responsible for refilling the stock, forgot to check the number of materials in a certain operating room, resulting in a shortage |
| HSS (Slips) | – | |
| HST (Tripping) | – | |
| Other | ||
| PRF (patient-related factor) | 2 | First surgery procedure was performed in another country where other types of orthopaedic materials were used. Other instruments were needed when this was noticed. |
| X (Unclassifiable) | – | |
↵* Each single incident can have multiple root causes; only incidents are used that resulted in more than 15 min delay.