Fatsa State Hospital operating room unit risk analysis method with determination and evaluation of near misses event

ABSTRACT Objective: The basic principles of Health Quality Development and Accreditation are directly related to determining, reasoning and prevention of near miss events that are effective, efficient, fair, safe, patient-patient affinity-focused and promised at the time of promise. In this study it was aimed to determine and evaluate nera miss events that may affect the health and safety of employees and patients in Fatsa State Hospital Operating Room Unit, taking into consideration the risks stemming from machine and installation, interpersonal communication, activities carried out, employee and / or workflow errors, and risk analysis study and taking precautions according to the results of these analyzes. Method: A survey was implemented to the randomly-chosen 25 employees working in operating unit at Fatsa State Hospital to measure the awareness about risk, risk analysis and near miss incidents. According to the results of the survey, an awareness training was implemented to the unit employees and a meeting aiming at gaining and sharing authority and responsibilities of the employees was held just 25 minutes before labouring. In the second meeting, job-stream sheme was examined accompanying with the unit employees and near miss incidents for the operating meeting were identified. In the third meeting, the identified near miss incidents were practised through fish-bone methodology (effect-reason analysis) and a root-reason analysis was performed. In the fourth, the last meeting, the root-reason analysis was performed and the risk level of the near miss incidents were determined using the risk management instructions at Dokuz Eylül University. Results: According to the survey aiming at identifying the updating and consolidation of the information, it has been brought out that the unit employees were not included in the risk analysis studies and any near miss incidents were not identified and any awareness was not created for the operating unit employees. Through training courses the unit employees have been informed about the near miss incidents, risk analyzing studies and risk management. The 11 near miss incidents have been determined for the operating unit employees and according to the results of the root-reason analysis, the personnel shortages, busy workstream based on performance, rushing to finish the duty and the lack of reliable surgery implementation have been identified as the main reasons. According to the results of the risk analysis of the 11 near miss incidents, the risk level of the tree was identified as very low and the six, at low level and the two at medium level. Conclusion: Offering the basic principles of the quality in health ; efficient productivity, being fair and reliable for everyone , being punctual and patient-focused services are available through indentification of near miss incidents and analyzing the reasons and evaluating and implementing corrective activities. In addition, increasing the surgery care quality, providing the surgery security and preventing the near miss incidents and improving patients' care, that is, implementing reliable surgery control list for offering trustful health service and working focused on patient have been stressed on. Key Words: Near miss event, risk analysis, risk management,