Enhancing patient safety: identifying fall risks during patient transfers in operating rooms

Abstract

Background

Transfers within operating rooms present significant risks to patient safety, with falls potentially leading to serious consequences for both patients and staff. The aim of this study is to explore the factors contributing to falls during transfers and strategies to enhance patient safety in operating rooms.

Methods

This is a qualitative study conducted using semi-structured interviews with fifteen operating room staff including nurse (n = 7), anaesthesia technician (n = 7) and scrub person (n = 1). Their ages ranged from 28 to 39 years, with experience years in the operating room ranging from two to ten years. The data were analysed using a thematic analysis approach based on the grounded theory.

Results

The thematic analysis identified six key factors contributing to falls during patient transfers: human error, team coordination, patient condition, staffing challenges, equipment issues, and inadequate training. Participants recommended improving team collaboration, pre-operative patient education, better infrastructure (e.g., private elevators), hands-on training, and increased staffing. Additionally, policy changes to limit complex outpatient transfers were suggested to reduce risks.

Conclusions

This study provides valuable insights into the risk factors and potential prevention strategies regarding falls during patient transfers in operating rooms. Future research should incorporate multidisciplinary observational studies involving human factors to provide deeper insights. It is recommended to create systems for anonymous incident reporting and implement comprehensive training programs.

Background

Patient transfers within operating rooms (ORs) present significant risk factors for patient safety, especially during transitions between stretchers and operating tables. Falls during these transfers, while relatively rare, are often preventable with the implementation of targeted safety measures, making them a critical focus for enhancing patient safety [1]. A review of 8,337 perioperative safety reports from 2014 to 2020 identified that 1% were classified as fall-related events, with 86 recorded falls occurring in perioperative settings [2]. Among these, one of the most frequently reported fall scenarios involved patients falling from a bed or stretcher (15% of all perioperative falls).

While patient falls are widely recognised as a serious and preventable safety issue across healthcare settings, the specific risks associated with OR transfers remain underexplored in the literature [3]. Exploring the factors that contribute to falls during patient transfers is essential, specifically, to develop targeted prevention strategies. This highlights a gap in understanding how best to address and reduce these fall risks. Gaining insights from staff is crucial for identifying weaknesses in existing procedures and developing practical, tailored solutions to reduce fall incidents and improve patient safety.

This study, therefore, aims to explore operating room staff’s experiences and views about factors contributing to falls during transfers and strategies to enhance patient safety in operating rooms.

Methods

Design

This is a qualitative study based on a grounded theory. Face-to-face semi-structured interviews were used to gather in-depth insights from healthcare professionals involved in patient transfers in ORs. The qualitative approach was chosen to understand the situation-specific experiences of the participants, enabling a comprehensive exploration of their perspectives on patient safety and fall prevention during transfers. This design provided participants with the flexibility to express their views freely, while ensuring that essential topics were consistently addressed throughout the interviews.

Sampling

The study involved 15 participants (Table 1), all healthcare professionals working in ORs at various city hospitals with the number of ORs ranging from 10 to 27 in Turkey. Their ages ranged from 28 to 39 years, with experience years in the OR ranging from 2 to 10 years. The participants’ roles included nurses (n = 7), anaesthesia technicians (n = 7), and one scrub person. A predetermined sample size was not necessary for this study design. This study is based on a grounded study which involves creating theories while collecting and analysing data at the same time [4]. The researcher alternated between gathering data and analysing it, refining theories along the way. This process continued until no new information is found, which is called “data saturation”.

Table 1 Participant characteristics

Data collection

Data collection tools included a demographic information form and an interview form. The demographic information form was developed to collect essential participant data, including age, years of experience in the OR, place of employment, and the role in the OR. Semi-structured interviews were conducted following the flexible nature of the qualitative study design. An interview guide form was created in align with the aim of the study and informed by the researcher’s professional background in patient safety, prior observations related to patient transfers. The questions were not strictly followed in order, allowing for a more natural conversation. The guide was piloted with two individuals from the target population and two health science experts to evaluate its clarity and completeness. As the questions were found to be clear and understandable, no major revisions were needed.

The participants were reached by using snowball and chain method, which are purposeful sampling methods. The data were collected between 15 August and 17 September 2024. The sampling process was initiated after a scrub nurse informally raised concerns about patient falls during transfers in the operating room. This interaction sparked the researcher’s interest, leading to the development of the study. The same scrub nurse was recruited as the initial participant, and the snowball sampling technique was then used to identify additional participants. The first participant referred the researcher to other healthcare professionals working in ORs, who were subsequently invited to participate in the study. This method allowed for the recruitment of a diverse range of professionals experienced in patient transfers in various hospital settings.

All interviews were conducted face-to-face by the lead researcher, who has prior training and experience in qualitative research and has previously conducted similar studies in clinical settings. The interviews took place in a quiet, suitable location chosen at the time of each session and were audio-recorded with participants’ verbal consent. At the beginning of each interview, the study purpose was explained clearly to the participants.

Data management and analysis

The audio recordings were transcribed verbatim into Microsoft Word 2020, with each document labelled numerically (e.g., the first interview was labelled Participant 1). Once the transcription process was completed, the original audio files were deleted. The transcripts were analysed manually using a thematic analysis approach based on the grounded theory. The analysis process began with coding and labelling recurring topics after multiple readings of the transcripts. Similar labels and topics were grouped to form sub-themes, which were then organized into overarching themes. Additionally, the frequency of specific words or phrases was noted to highlight the significance of each theme, utilizing a quasi-statistical approach to emphasize the prominence of themes.

Reflexivity

The researcher of this study has a background in physiotherapy and a doctoral degree in healthcare ergonomics and patient safety have shaped the approach to data collection and analysis. The experience with various research methods, including interviews, focus groups, and postural analysis, has informed the understanding of the complexities involved in patient safety and fall prevention. Acknowledging that prior knowledge and perspectives could affect how participants’ responses were interpreted, the researcher practiced reflexivity throughout the study. This involved being aware of potential biases and working to minimize their influence by following the interview guide closely and ensuring that themes were derived directly from the data, rather than from preconceived ideas.

Results

Participants emphasized that the key to the patient transfer process is ensuring safety. They described the procedure as follows: first, the stretcher’s brakes are engaged. If the patient can move, an anaesthesia technician and nurse assist them onto the operating table. If the patient cannot move independently, the team carefully position and transfer them, working together to manage the weight and protect themselves. The stretcher is aligned with the operating table, ensuring that there are no gaps. The patient is either assisted or, if necessary, extra staff are called in to facilitate the transfer. After the procedure, the process is reversed: the stretcher is aligned, the brakes are locked, and the patient is carefully transferred back to the stretcher. Throughout the process, the focus remains on safety, proper body alignment, and minimizing disturbance.

Participants described a collaborative process for patient transfers involving several key roles. The service nurse prepares and hands over the patient, while the operating room staff, including nurses and anaesthesia technicians, assist in transferring the patient onto the operating table. The surgeon decides the patient’s position and oversees the transfer. Auxiliary health personnel, porters, and the surgical team all contribute to ensuring the patient’s safety and coordinating the transfer, with a focus on maintaining smooth and secure procedures throughout.

Three participants reported varying experiences with falls during patient transfers. One participant described an instance where an obese patient fell between the stretcher and the operating table due to a tear in the sheet but was caught and prevented from hitting the ground. Another experienced a fall when the stretcher’s brakes were not engaged properly, leading to the patient falling. Additionally, a participant mentioned injuring their shoulder while trying to prevent a fall, though the patient may not have fallen. Overall, experiences with falls were infrequent, and several participants had not encountered any such events.

Factors contributing to falls

Six themes and sixteen sub-themes were identified related to factors contributing the falls in ORs (Table 2).

Table 2 Themes and sub-themes

Human error and safety oversights

This was the most frequently mentioned theme in the participants’ responses. Many participants highlighted issues such as attention lapses (six mentions) and safety neglect (four mentions), describing situations where a lack of focus or disregard for established safety protocols led to risky situations during patient transfers.

“Main factors contributing to falls are carelessness and negligence; not using patient belts correctly.” (P1)

“Carelessness is the main factor for falls, for example taking the patient from the stretcher to the operating table when the stretcher brakes are not turned off.” (P4)

“Inattention to the stretcher lock would cause the falls.” (P7)

Inadequate precaution and hasty actions were also common concerns, with some participants pointing out that rushing through the process or failing to take proper precautions increased the likelihood of accidents.

“Stretchers can slide when they are not locked during transfer, and they are carried from one table to another by pulling without any protection.” (P15)

“In a rush to complete the transfer quickly, we may overlook safety precautions.” (P13)

Inexperience was another contributing factor, where less experienced staff were more likely to make errors or overlook critical safety steps, further compounding the risks involved.

“New staff often lack the confidence to handle transfers. They hesitate or make mistakes, which can put the patient and the team in danger.” (P5)

Team coordination and collaboration

This theme emerged as a significant factor influencing the safety of patient transfers. Participants frequently mentioned issues with inadequate coordination, where team members were not always aligned in their actions or communication during transfers, leading to confusion and potential safety risks. Similarly, a lack of collaboration was highlighted, with some participants noting that the absence of teamwork, particularly when staff members did not support one another or share responsibilities, increased the likelihood of errors and jeopardised patient safety.

“I think team unity is achieved more in other units.” (P7)

“Not acting in a coordinated manner may result in stretcher security” (P9)

Patient condition

Participants emphasized various patient-related factors that influenced the transfer process. Mobility limitations were frequently cited, as patients with restricted movement required more careful handling and increased staff involvement. Sedated or unconscious patients presented additional risks, as their inability to assist in the transfer required more care and precision. Additionally, agitation of patients complicated the transfer process and required more effort to ensure the safety during the procedure.

“Since the patient is not conscious after anaesthesia, he may throw himself, there should always be someone with him.” (P3)

“Agitated patients, children or disabled patients can be extremely mobile; therefore, it is not possible for one employee to hold the patient and pull the stretcher simultaneously.” (P10)

Staffing and workload management

Participants frequently mentioned staffing and workload management as key challenges during patient transfers. Inadequate staffing, highlighted by several participants, often led to increased pressure on the available personnel, making it difficult to ensure safe transfers. Additionally, the lack of involvement from the team members raised the possibility of mistakes as the remaining personnel had to manage the transfer process on their own with little assistance.

“Most of the time, the number of people in the team is insufficient.” (P14)

“If I find a few people, I call them to hold the patient.” (P15)

“The surgical team and the nurse are not involved in the transfer.” (P11)

Equipment issues

Participants frequently highlighted equipment issues as a significant barrier to safe patient transfers. Improper use of available equipment, such as failure to secure brakes or misuse of transfer aids, was commonly mentioned as contributing to safety risks. Additionally, the lack of necessary equipment forcing staff to rely on manual handling methods, which increased the risk of injury to both patients and staff.

“The fact that institutions try to do more work at less cost is a factor that makes it difficult to take the necessary precautions.” (P5)

“Without a reliable sliding system, transferring patients becomes risky.” (P10)

“One time, as we were transferring a patient from the surgical table to the stretcher after surgery, the patient fell because the stretcher’s legs were not properly locked.” (P14)

Inadequate training

This theme highlights the impact of inadequate staff preparation on patient transfers. Participants often reported receiving minimal or no hands-on training, relying mostly on brief online courses or verbal instructions. This lack of comprehensive, practical training leads to difficulties in managing patient transfers safely and effectively, highlighting the need for more thorough and interactive training programs.

“We received verbal training.” (P3)

“I have not received any training; our hospital has no training on this subject.” (P7)

“Instead of giving so-called training to people working in the field through the system, there should be practical training in the field.” (P5)

Recommendations for improvement

Based on participants’ experiences and insights, several key areas for enhancing patient safety during transfers were identified. These suggestions focus on improving team collaboration, patient preparation, equipment adequacy and quality, staff training, and hospital policies. Addressing these recommendations could significantly reduce the risk of falls and injuries, creating a safer environment in operating rooms. The following section outlines the proposed improvements in detail.

Team involvement and coordination

Participants emphasized the need for better collaboration during patient transfers. They suggested that all team members, including surgeons, should be more involved in the hands-on aspects of the transfer process. This would improve coordination and reduce errors, as every role would be aligned with the patient’s safety at the forefront.

Patient preparation and education

Several participants stressed the importance of preparing patients better before surgeries. Pre-operative education could help patients understand the process, reducing their anxiety and agitation during transfers. Additionally, ensuring that patients arrive and depart with a companion, and that they are pain-free and alert, would facilitate smoother and safer transfers.

Infrastructure and equipment improvement

Participants noted that upgrading the infrastructure and equipment used during transfers would significantly improve safety. Suggestions included installing private elevators specifically for patient transfers, using transfer boards, and implementing rail systems to minimize the risk of falls. More advanced and better-equipped stretchers were also highlighted as critical to ensuring safe transfers.

Staff training and support

There was a strong call for more comprehensive and practical training for staff involved in patient transfers. This would include specific education for porters on the correct use of stretchers and more hands-on training sessions. Moreover, participants suggested increasing staff numbers to better distribute the workload and ensure safer transfers.

Policy changes

Lastly, a key policy recommendation was to avoid accepting outpatients for surgeries that require complex transfers, as these cases present additional risks and challenges in ensuring patient safety.

Discussion

This study explored operating room staff’s experiences and perspectives regarding the factors contributing to patient falls during transfers and the strategies to enhance safety. The findings showed that safety is a key focus during patient transfers, with staff following a detailed process involving locked brakes, aligned stretchers, and teamwork to position patients. However, some participants (three out of 15) reported falls, highlighting safety concerns for both patients and healthcare professionals. This suggests that such incidents may be more common than previously recognized in similar settings. For instance, a study analysing safety reports from 2014 to 2020 found that falls accounted for just 1% of safety incidents [2]. This discrepancy highlights the potential underreporting of falls and emphasizes the need for further investigation.

Human error was the most frequently cited factor contributing to falls during patient transfers. Participants identified attention lapses, safety neglect, and hasty actions as recurring risks, which often compromised patient safety. This aligns with existing literature, where human error has been widely recognized as a significant contributor to adverse events in perioperative settings [5, 6]. The pressure to complete transfers quickly or without full attention to detail can increase the likelihood of mistakes, such as forgetting to lock stretcher brakes or failing to position the patient correctly. Additionally, the involvement of inexperienced staff was reported as further exacerbating fall risk. This may be attributed to their lack of confidence, limited skills, and insufficient knowledge of proper transfer procedures. Previous studies have shown that inexperienced staff tend to be less aware of potential hazards, are more prone to making errors, and often struggle to apply safety regulations correctly, particularly when they do not receive adequate guidance from more experienced team members [7, 8]. In healthcare settings, patient transfers require skill and situational awareness, which are gained through experience and training [9]. Without adequate support, inexperienced staff may overlook safety risks, leading to adverse events. Therefore, it is essential to implement structured training and mentorship programs to reduce human errors.

A critical finding from the study was the issue of insufficient training, which emerged as a primary factor limiting staff’s ability to manage patient transfers effectively. Furthermore, insufficient training is closely linked to improper use of equipment, a critical issue identified by the participants in the current study. The lack of proper education regarding equipment usage, such as stretchers, transfer boards, and other tools, can result in misuse or failure to use the equipment as intended, further compromising patient safety. This highlights the need for more comprehensive, hands-on training programs. This finding aligns with research suggesting that training should be ‘brief but often,’ emphasizing ongoing and practice-based education [10]. Addressing these issues aligns with findings from related studies that underscore the importance of training in fostering a positive safety culture. For instance, staff in a study reported that education not only improved their knowledge about fall prevention but also fostered teamwork and collaboration [11]. A recent Nigerian study also identified inadequate training and poor communication among healthcare teams as major factors compromising patient safety [12]. Team coordination and communication are critical factors in preventing errors during patient transfers [13, 14]. This issue was emphasised in the study, with participants noting that a lack of clear communication and coordination among team members led to confusion and mistakes during transfers. A related study found that a well-established surgical schedule is essential for informing staff about their assigned roles and tasks, enhancing overall coordination [15]. Furthermore, in the current study, a lack of clear communication among team members was found to result in staff members not supporting each other, sharing responsibilities, and increased likelihood of errors, which compromised patient safety during transfers. This is consistent with findings of Bre et al.’s [16] study examining the impact of workflow changes in neurosurgery. They found that briefing and debriefing by using a custom mobile platform helped increasing safety, efficiency, and team collaboration and reducing last-minute requests by improving communication between team members.

Participants also highlighted challenges related to staffing and workload management, where inadequate staff numbers and a lack of involvement from all team members increased the likelihood of errors. Staff shortages and increased workload on the remaining staff can increase the likelihood of errors and reduce the effectiveness of safety measures during patient transfers [12, 17, 18]. This challenge is further exacerbated by issues in perioperative nursing, including an aging workforce, high turnover, and difficulty in recruiting new staff [19]. A holistic approach is recommended to manage staffing workload by combination of recruitment of new staff and retention of existing staff.

Patient conditions, including mobility limitations, sedation, and agitation, were highlighted by participants as significant risk factors requiring careful management to prevent incidents during transfers. The literature supports this, noting that common patient-related factors contributing to falls in ORs include gait and balance disturbances due to anaesthesia, dizziness and confusion from use of multiple medication, and disorientation in unfamiliar environments [20]. While some factors are fixed and cannot be changed, adaptive approaches and preparation should be developed. Participants in this study emphasized the need for better patient preparation before surgery. Preoperative education can help reduce patient anxiety and agitation by informing them of what to expect, leading to smoother, safer transfers. Furthermore, ensuring that patients arrive and depart with a companion and are as pain-free and alert as possible can enhance the overall safety of the transfer process.

This study provides valuable insights of healthcare professionals’ real-life experiences with patient falls during transfers in the OR, which is a high-risk, under-researched environment. A key strength lies in using thematic analysis grounded in real-world data, offering a comprehensive understanding of fall risk factors during patient transfers. The diverse range of participants strengthens the study’s relevance across various OR roles. However, the absence of surgeons and patients as participants limits insights related to team coordination and patient-centred perspectives. Unlike prior studies that often generalise fall risks across various hospital settings, this study provides a focused exploration of fall risks specifically during intraoperative patient transfers. On the other hand, the study’s findings, being context-specific, may not be generalisable across different healthcare systems or regions. Future research could benefit from larger, multi-centre studies that include perspectives from surgeons and patients, alongside quantitative data to expand on these findings.

Implications and recommendations

This study contributes to the literature by informing context-specific safety strategies and highlighting overlooked occupational hazards faced by surgical teams during manual handling. The findings revealed that safety is the central focus during patient transfer procedures, involving detailed, collaborative steps to mitigate risks. Despite this, incidents of falls, were reported by some participants, implicating safety issue for both patients and healthcare professionals. The thematic analysis revealed six key themes contributing to falls: human error, team coordination, patient condition, staffing challenges, equipment issues, and inadequate training. Among these, human error—particularly attention lapses, safety neglect, and inexperience—was most frequently cited. Insufficient team communication and coordination further noted as contributing to errors, while patient-specific factors such as limited mobility and sedation introduced additional complexity.

The study highlighted key areas for improving patient safety during transfers in operating rooms:

• Enhance Team Collaboration: Involve all team members, including surgeons, porters, and nurses, to ensure better communication and coordination during transfers.

• Improve Patient Preparation: Provide preoperative education and ensure patients are accompanied, alert, and pain-managed where possible to reduce transfer risks.

• Improve Equipment and Facilities: Use better stretchers, transfer boards, and rail systems. Add features like private elevators for safer patient transfers.

• Increase Staffing and Training: Address staffing shortages and implement hands-on, practical training focused on patient handling, communication, and use of assistive tools.

• Review and Revise Policies: Consider policy changes to reduce complex outpatient transfers that carry heightened risk, especially those involving patients under sedation or pain.

• Promote Safety Culture: Establish an anonymous incident reporting system to encourage staff to report near-misses and adverse events safely, helping the team learn and improve.

These recommendations, drawn from frontline healthcare professionals, aim to reduce the incidence of falls and improve the overall safety culture in ORs. Future research should include observational studies that actively engage patients, surgeons, and human factors specialists to provide a more holistic understanding of safety gaps.