The Effects of Using Intraoperative Care Documentation Forms on the Number of Reported Errors

Background: Reporting intraoperative errors can help reduce the incidence of more errors. However, some errors remain unreported. A key strategy to improve error reporting is quality care documentation. Objectives: The aim of this study was to determine the effects of using intraoperative care documentation forms on the number of reported errors. Methods: This single‑group pretest–posttest interventional study was conducted on 65 operating room technicians and nurses recruited from the operating rooms of Alzahra and Kashani Teaching Hospitals, Isfahan, Iran. A researcher‑made error‑reporting questionnaire was used to assess the rate of reported and unreported errors both 1 week before and 2 months after the study intervention. During the study intervention, participants were asked to perform intraoperative care documentation for 2 successive months using five researcher‑made intraoperative care documentation forms. Data were analyzed through the McNemar’s and Wilcoxon tests and the Spearman’s correlation analysis. Results: The mean score of intraoperative care documentation had a direct correlation with the number of written‑reported errors (P = 0.044) and an inverse correlation with the number of unreported errors (P = 0.047). The number of written‑reported errors significantly increased (P = 0.009), whereas the number of unreported errors significantly decreased after the study intervention (P = 0.017). Conclusion: Intraoperative care documentation can significantly increase the rate of error reporting. Therefore, the intraoperative care documentation forms developed in this study can be used to improve operating room staff’s documentation and error‑reporting practice.