Development and implementation of an intraoperative documentation protocol for enhancing patient safety in the operating room: A mixed methods protocol study

BACKGROUND: Documentation is an important part of the patient care process; however, there is no regular program for documenting intraoperative care in Iran. This study was conducted to design an intraoperative documentation for enhancing patient safety in the operating room (OR).MATERIALS AND METHODS: This exploratory, mixed-methods, qualitative-quantitative study (in 2021) consists of four phases. The first phase involves a conventional content analysis of healthcare providers in the OR to identify the needs, strategies, and content of a pertinent documentation. In this phase, purposeful sampling will be used to collect data through semi-structured interviews. In the second phase, a literature review will be carried out to extract the documentation procedures in the intraoperative period in many other countries. In the third phase, a panel of experts is recruited and the classic Delphi (RAND) technique is run to validate the initial draft of the designed program and, the protocol is then finalized. In the last phase, the designed protocol will be implemented through a quasi-experimental study in one group (before and after intervention), and the effectiveness of the intervention will be evaluated.DISCUSSION: To design a protocol for intraoperative documentation, healthcare providers' experiences during surgery in the Iranian healthcare setting, where the lack of documentation might forensically harm both the healthcare providers and the patients, will be explored. This information alongside some universal standards developed in other countries should help improve patients' safety in ORs.