Anne van Dalen

150 I Chapter 4 ORGANIZATION Sub-category Code Description OR Resource Mismanagement Inadequate resource allocation Inadequate allocation of necessary surgical resources to surgical tool sets (Ex. Tool shortage, not enough to go around) Inadequate resource procurement Failure to procure necessary/ preferred surgical tools/materials (Ex. Bad purchasing decisions) Support services unavailable Lack of support for troubleshooting intraoperative issues (Ex. No technical support staff available when needed) Safety Culture Deficiencies Inadequate risk resolution Recurrent issues arising in the OR that have the potential to compromise safety are inadequately communicated/ resolved Unsafe staffing Ex. Not enough staff present for current procedure; staff present are working post-call Perioperative Process Failures Inaccurate documentation Preoperative documentation issues, inconsistencies/errors/ inaccuracies in patient record Incomplete information Information available to clinicians is insufficient for adequate case preparation Ex. Indicators used to approximate case difficulty/potential challenges do not sufficiently reflect actual difficulty Suboptimal Policies/ Procedures No safety check No protocol mandating clinicians to check with/communicate with team prior to execution of critical procedure step