Assessment of Factors Leading to Patient Positioning Errors During Surgical Procedures in Tertiary Care Hospital
DOI:
https://doi.org/10.65761/pjcr.2026.142Keywords:
Patient Positioning, Medical Errors, Intraoperative Complications, Surgical Procedures, Operative, Tertiary Care CentersAbstract
Background: Patient positioning errors during surgical procedures are a significant concern as they can lead to serious intraoperative and postoperative complications, particularly pressure injuries.
Objective: This study aimed to assess the factors leading to patient positioning errors in the operating room of a tertiary care hospital, identify common positioning errors, determine patient-, procedure-, and team-related factors, and evaluate their association with pressure injuries.
Methods: A descriptive cross-sectional study design was employed over a period of six months. A total of 168 operation theatre (OT) staff members were selected using a convenience sampling technique. Data were collected through a structured self-administered questionnaire and analyzed using SPSS version 26. Descriptive statistics were applied, and statistical analysis was performed using the Chi-square test.
Results: The results revealed that most positioning errors were of low severity, with the majority of cases falling under error score 1. However, errors were commonly observed across different surgical positions, with the highest frequency in the supine position. Statistically significant associations were found between positioning errors and surgical specialty (p = 0.003) as well as duration of surgery (p < 0.001), indicating that longer and more complex procedures increased the risk of errors. Furthermore, a strong association was observed between patient positioning and the development of pressure injuries (p < 0.001), with the highest occurrence reported in supine, lithotomy, and prone positions.
Conclusion: Although most positioning errors were of low severity, they occurred frequently and were significantly associated with procedure-related factors. Improper and prolonged positioning increases the risk of pressure injuries. Therefore, strict adherence to positioning protocols, continuous monitoring, and proper training of surgical teams are essential to enhance patient safety and reduce complications.
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Copyright (c) 2026 Zarnish Fatima, Fakhra Fakhr, Ifra Noor, Shahid Ijaz, Muhammad Mohsin Yar, Anas Jahangir
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