Evaluation of the frequency of 28 errors (Never Event) and related factors in the operating room in hospitals of Lorestan University of Medical Sciences in a period of 2 years (April 2018 to March 2020).

Background and Objectives: 28 Errors or Never Events are cases that should never happen and in case of occurrence, the Vice Chancellor of the University should be informed immediately and the Vice Chancellor should inform the Office of Supervision and Accreditation of the Deputy Minister of Health within a maximum of 6 hours. Materials and Methods: The present study is a retrospective cross-sectional analytical study that was performed on all operating rooms of public hospitals under the auspices of Lorestan University of Medical Sciences, which have completed the 28 events reporting form. Data were analyzed using SPSS software version 16 and descriptive and inferential statistics. Results: The results showed that the highest frequency of errors was related to death or complication of mother and infant following cesarean section (58.3%). Also, a significant relationship was found between the incidence of errors with age group, type of hospital and the day of the accident, but not with other variables. Conclusion: Due to the importance of death and complications of mother and infant in the operating room, it is recommended to avoid unreasonable cesarean section if possible and to use skilled midwifery and anesthesia personnel and complete resuscitation equipment in the operating room.