Sentinel events, a burden in the operating room: A literature review

Abstract

Context: Despite the existence of diverse integrated surgical safety measures pre-, intra-, and post-operatively globally, preventable adverse medical errors still occur to the patients in the operating rooms and has been regarded as the major cause of temporary or permanent disability and death among the victims.

Aim: The purpose of this paper is to explore sentinel events in the operating rooms

Materials and Methods: A comprehensive literature search was conducted across the electronic databases PubMed/MEDLINE, Embase, Conchrane and Google Scholar to source numerous articles on the subject matter. The articles search was between 2005 and 2026. Terms were combined using Boolean operators such as “Sentinel” AND “events,” “operating room” AND “surgical team members”.

Results: Various forms of sentinel events occur in the operating room but the common ones are fall, wrong-site surgery, retained surgical items, and operating room fire. Factors responsible for these events in the operating rooms are organizational factors such as limited policies, lack of perioperative protocols, and staff shortage Effective communication between the patient and surgical team members are crucial preventive measures against sentinel events in the operating rooms.

Conclusion: It is pertinent for surgical-team to be knowledgeable about patient safety. Also, standard practice protocol should be entrenched to limit sentinel events in the operating rooms.