System Level Harmful Contributing Factor Protective Contributing Factor Patient The patient was dehydrated from being NPO (nothing Characteristics by mouth) and having a bowel preparation. Task Factors The was exposed during surgery. There is an intraoperative upper body warming protocol. patient’s midsection The abdominal cavity was irrigated with Irrigation is warmed. patient’s saline before closure. The temperature probe might not be accurate. Individual Provider The OR staff like to work in a cool OR. Factors Lack of role clarity regarding who is responsible for Team Factors normothermia maintenance. Normothermia is a lower priority during the OR Patient warmers are readily available. Work Environment case. Departmental Staff from the entire perioperative area are working together on the Factors Safety Program for Surgery. The central stores department reliably delivers patient warmers to Hospital Factors perioperative units when needed. Institutional Factors Hospital leadership prioritizes patient safety.
System Level Harmful Contributing Factor Protective Contributing Factor Patient Characteristics The patient was dehydrated from being NPO (nothing by mouth) and having a bowel preparation. Task Factors The patient’s midsection was exposed during surgery. There is an intraoperative upper body warming protocol. The patient’s abdominal cavity was irrigated with saline before closure. Irrigation is warmed. The temperature probe might not be accurate. Individual Provider Factors The OR staff like to work in a cool OR. Team Factors Lack of role clarity regarding who is responsible for normothermia maintenance. Work Environment Normothermia is a lower priority during the OR case. Patient warmers are readily available. Departmental Factors Staff from the entire perioperative area are working together on the Safety Program for Surgery. Hospital Factors The central stores department reliably delivers patient warmers to perioperative units when needed. Institutional Factors Hospital leadership prioritizes patient safety.