Evidence map›Paper›PMID 39845404›Full record

ArticleRisk management and healthcare policy2025

Systematic Risk Analysis and Mitigation Strategies for Near-Miss Events in Interventional Operating Room Nursing.

Ling-Yu Ma, Rong-Fang Shan, Yong Lu, Lu-Yi Cong, Hai-Yan Gu

Abstract read
In one paragraph

Article in Risk management and healthcare policy, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

5 authors.

Ling-Yu MaDepartment of Operating Room, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.
Rong-Fang ShanDepartment of Operating Room, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.
Yong LuDepartment of Operating Room, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.
Lu-Yi CongDepartment of Operating Room, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.
Hai-Yan GuDepartment of Nursing, Affiliated Hospital 2 of Nantong University, Nantong, 226001, People's Republic of China.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Purpose: The aim of this study is to examine the characteristics of intraoperative nursing near-miss events in interventional operating rooms, systematically identify and analyze associated risks, and propose effective mitigation strategies. Patients and Methods: A retrospective study was conducted using a specially designed survey focused on nursing near-miss events in Interventional operating rooms. Records of intraoperative near-miss events voluntarily reported by medical and nursing staff between January 2023 and March 2024 were analyzed. Grey relational analysis was used to evaluate and identify the associated risk factors. Results: A total of 81 near-miss events were reported, with the majority (50%) occurring after 8 PM. These events were categorized into 6 main types: medication errors (60.49%), issues with consumables (16.05%), tubing-related incidents (8.64%), specimen handling errors (7.4%), transfer handover issues (4.93%), and patient transport problems (2.46%). Grey relational analysis identified air embolism formation during pressurized fluid administration as the highest risk event (ξ1 = 0.369). The risk factors were ranked as follows: weak coordination ability and lack of responsibility among nurses > operational interruptions > inadequate professional capability > poor communication between medical staff and nurses > equipment malfunction > frequent emergency surgeries and a fast paced working environment. Conclusion: Medication administration errors are frequently encountered, with air embolisms during pressurized fluid infusion representing the most significant risk. Operational interruptions are major contributors to these errors, often influenced by the coordination skills and professional competencies of nurses. Clinically, it is crucial to enhance the identification and management of near-miss events to reduce the incidence of adverse outcomes during surgical procedures.

Indexed as

grey relational analysisinterventional surgerynear-missprevention and rectificationrisk factors

Identifiers

PMID39845404
PMCPMC11752924

What Socratic holds

Textmetadata
LicenceCC BY-NC
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.