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Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks
  1. Dirk F de Korne1,2,
  2. Jeroen D H van Wijngaarden2,
  3. Jeroen van Rooij3,
  4. Linda S G L Wauben4,
  5. U Frans Hiddema5,
  6. Niek S Klazinga6
  1. 1Rotterdam Ophthalmic Institute, The Rotterdam Eye Hospital, Rotterdam, The Netherlands
  2. 2Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  3. 3Corneal Diseases and Infection Prevention and Control, Rotterdam Eye Hospital, Rotterdam, The Netherlands
  4. 4Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
  5. 5Executive Board, The Rotterdam Eye Hospital, Rotterdam, The Netherlands
  6. 6Department of Social Medicine, University of Amsterdam, Amsterdam, The Netherlands
  1. Correspondence to Dirk F de Korne, Rotterdam Ophthalmic Institute, The Rotterdam Eye Hospital, and Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 70030, 3000 LM Rotterdam, The Netherlands; d.dekorne{at}


Objective To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned.

Methods The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics.

Results Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR.

Conclusions OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.

  • Human factors
  • clean air flow
  • infection control
  • quality measurement
  • patient safety
  • continuous quality improvement
  • crew resource management
  • health services research
  • quality improvement
  • information technology
  • evidence-based medicine
  • healthcare quality improvement
  • diagnostic errors
  • hand-off
  • teamwork
  • surgery

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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