ROOT CAUSE

ANALYSIS
Suggested
Solutions
 • Suggested solutions
• Proper resident-to-
resident referral
• Adequate preoperative
↑ Number  evaluation and preparation
of deferred  including timely referral for
clearance and follow-
cases up of patients
• Secure implants and other 
necessary materials for the s
pecified procedure
 • Suggested solution:
People • Complement OR staff
 • Suggested solutions:
• Wheel-in
patient at 6:30am (for first cases).
• Suggest that patients may be wheeled 
in at the OR 15-30 minutes
prior to end of the disinfection.
• Residents in-charge
Turn-over time of the case should be present
during positioning and before induction 
of the case.
issue • Prompt referral to senior/consultant if   
with difficulty intraoperatively (for         
 surgeons) and during induction (for         
anesthesiologist).
• Have all equipment and materials
specific for the procedure prepared at 
the OR prior to commencement of anesthe
sia
 • Suggested solutions:
• Suggest to shorten disinfection 
 time since the patients catered 
Disinfection  at the OR are already RT-
issue PCR negative. If in case the
patients are only RAT-
negative, then the policy
regarding this case should apply.
• Additional suggested solutions:
• Double-table of cases were done to cater more elective procedures
in a day
OTHER CONCERNS
1. Double Table Cases
2. Physician's Order Sheet Entry
3. MDT
4. Availability of Consultants for
certain OR Procedure
THANK
YOU