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Perioperative process errors and delays in otolaryngology at a Veterans Hospital: Prospective study


  • Presented at the American Academy of Otolaryngology–Head and Neck Surgery Annual Meeting, Washington, DC, September 9–12, 2012.

  • The authors have no funding, financial relationships, or conflicts of interest to disclose.



To understand the leading causes for process errors and delays in the otolaryngology operating room and recognize the impact of process errors and delays on patient safety, operating room resources and hospital costs.

Study Design

Prospective, observational study.


A 4-week study was conducted during 1 calendar month in 2012, evaluating 23 elective otolaryngology cases. A standardized data collection tool was developed and refined based on prestudy pilot observations. Two trained observers recorded relevant times and actions from patient check-in time in the preoperative holding area to the “wheels out” time.


The mean case observation time was 220.0 ± 167.8 minutes, with mean duration of operation length being 107.0 ± 146.2 minutes. The perioperative period was divided into six stages: patient holding, room preparation, preintubation, postintubation, intraoperative, and postextubation. One hundred process errors were recorded (average of 4.3 per case), 34% of which were due to communication failures. Forty delays were observed, resulting in 336 minutes of standstill delay. Again, communication failures represented the most common etiology, with 17 communication failures resulting in 146 minutes of standstill delay. The preintubation stage was most affected by delay, with 1 in 6 minutes comprising standstill delay.


Process errors and significant delays were common in cases performed at our institution; communication errors were the most common etiology. There is opportunity for preoperative team discussion and the use of technology to minimize communication-related process errors and standstill delays. Further work is currently being undertaken to study this critical issue across specialties.

Level of Evidence

2c. Laryngoscope, 123:3010–3015, 2013