Challenges of Intraoperative Documentation and Its Role in Patient Safety: An Integrative Review

Abstract

Background: Accurate and complete intraoperative documentation is crucial for maintaining consistency in patient care, facilitating handoffs between surgical teams, and evaluating outcomes. This integrative review aimed to investigate the challenges of intraoperative documentation and its role in patient safety. Materials and Methods: A search of English-language databases including EMBASE, Proquest, Web of Science, PubMed, ScienceDirect, and Scopus was conducted from 2001 to 2022 using the keywords “intraoperative documentation”, “patient safety”, “documentation”, and “intraoperative”. Results: Nineteen articles were included from the initial 86 identified studies. Key findings were that protocols, safe surgical plans, accurate documentation, error/complication prevention measures, teamwork, safety culture, checklists, and instrument/sponge counts positively impact patient safety. Conclusions: Operating rooms require precise patient information and documentation pre-, intra- and post-operatively. This review indicates intraoperative documentation can improve surgical team performance and patient safety by facilitating continuity of care, handoffs, and outcomes assessment.

Keywords

• documentation
• integrative review
• intraoperative
• medical record
• operating room
• patient safety
• safety culture